Prevention

It is always preferable to have no complications. This is rarely ever entirely possible, but there are many factors that can be controlled and deserve mentioning here.

First and foremost, the inexperienced or unskilled laparoscopic surgeon is more likely to have significant complications (133). Gaining experience and skill is mandatory. This is best done in a supervised well-controlled environment. Second, the instruments and equipment should be thoroughly familiar with the surgeon (71). Dull trocars, too small of an incision, uncontrolled forward force are all capable of producing catastrophic consequences, particularly major vascular injuries. Simple positional changes can facilitate complex maneuvers such as access, displacement of viscera, or allow straighter trajectory for an instrument. Perpendicular insertion of access instruments such as the Veress needle or trocar can lead to uncontrolled forceful insertions, which is asking for trouble. Lateral deviation of the needle or trocar can also shear into the abdominal wall or any underlying structures and should be avoided until full visual control has been established. An inadequate pneumoperitoneum reduces the working

Forceful thrusting with any laparoscopic device should never occur. As mentioned previously, force, especially in a closed pressurized environment, is never good.

Finally, make sure that all trocar insertion sites have an adequate skin incison to avoid insertion with unintended forward thrust.

Complications of laparoscopic surgery are a major concern for the patient and the surgeon. There is no doubt that the incidence of injury is proportional to the skill and experience of the surgeon.

Why would a urologist who has spent half a life time training and improving own skills at open urologic surgery wish to start a laparoscopic practice? The only answer lies in the fact that things go well, as they most often do, the patient does much better having not been traumatized to the degree that occurs during standard operative techniques. As Sir Alfred Cushieri has so eloquently phrased, "the ego of the surgeon must always be subservient to the needs of the patient."

space for the surgeon and impairs the ability to see peripherally. Whenever the field of view appears to become obscured, consider loss of pneumoperitoneum.

Forceful thrusting with any laparoscopic device should never occur. As mentioned previously, force, especially in a closed pressurized environment, is never good.

Anatomical landmarks should be sought, for laparoscopic anatomy is more statistical and less visual. That is to say, the probability of variability of anatomical structures especially vascular ones should always be forefront in the thoughts of the laparoscopic surgeon. During dissection and accidentally avulsing an accessory vein or artery is the wrong time to consider the possibility of it being there (134).

Finally, make sure that all trocar insertion sites have an adequate skin incison to avoid insertion with unintended forward thrust.

Port site herniation is an interesting problem from a preventative position. As in open surgery, the surgeon is near the conclusion of the operation and the fundamentals of closure can be at times rapidly applied or not fully attended (101,102). Some simple principles apply: do not remove a cannula with their flapper valves open, use the smallest trocar possible (risk of postoperative herniation varies directly with the trocar size), visualize the removal of each trocar, close the fascia of all cannula sites larger than 5 mm (in children and diabetics consider closing the 5 mm ones as well), shake the abdominal wall after the cannulas are removed and before placing fascial closure stitches to reduce the likelihood of viscera protruding into the trocar paths, and if the peritoneum is going to be closed, do so tightly. There are reports of underlying bowel and omentum protruding into large preperitoneal cavities following attempts to close the peritoneum. This could lead to small bowel obstruction and significant postoperative pain.

Supplements For Diabetics

Supplements For Diabetics

All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.

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