25, 50 and 75 years ago

The development of port site recurrences during laparoscopic surgery, in the presence of overt or covert malignancy, is a reflection of the process of metastatic dissemination. Early reports raised concerns that the incidence of port wound implants was increased by laparoscopic procedures. Features that drew particular suspicion included abdominal insufflation, increased and insensitive tumour manipulation as well as instrument and port exchanges. Animal experimentation supported the potential of those factors to potentiate wound metastasis. However, the artefactual nature and the failure to directly compare equivalent conventional and laparoscopic procedures limited the clinical relevance of a number of those studies. Experiments carried out in pigs reflected the direct relationships existing between tumour stage and operative procedures and the risks of wound implantation in both laparoscopic and conventional operations. Moreover, all commentaries considering port site recurrences had assumed that the risks of tumour cell contamination were greater in laparoscopic operations. Experiments testing that assumption indicate that laparotomies are, at least, equally at risk. The threat of a high incidence of port site metastasis indicated in the early reports has not been substantiated in light of subsequent experience. Emerging data from larger personal and multicentre clinical series indicate that the incidence of incisional metastases after laparoscopic colectomies for CRC does not differ sig- significantly from conventional surgery. Several of those studies also emphasize the link between lower port wound recurrences and regard for classic oncologic principles. In summary, clinical and experimental studies indicate that early reports of port site tumour recurrence were the results of early operative experience and technical problems that have been largely overcome by greater surgical experience and well-defined laparoscopic protocols based on the same oncological principles as in open surgery. Despite its importance the interface between tissue and instrument is poorly understood. A thin film pressure transducer (Fig. 1) was deployed between the jaws of eight different laparoscopic instruments and a simulated tissue to study the forces generated at the tip of laparoscopic graspers and the effect of a change in angle of tissue tension at the interface between tissue and laparoscopic grasper. Pressure was concentrated at the tip of the instrument. Localized pressures increased on average from 210 to 650 kPa as the angle of grasp was increased from 0° to 135°. There was a wide variation between instruments with some exhibiting increases in tip pressure of a factor of eight as the angle was increased. High pressures are generated at the tip of laparoscopic graspers. Pressures increase as the angle of incidence of the grasper in relation to the tissue increases. The changes in pressure with change in angle are independent of load and handle pressure. The care of the critically ill patient depends first and foremost on repeated clinical evaluation by knowledgeable medical attendants and nurses. This clinical evaluation must, however, be supplemented by a variety of monitoring procedures if optimum care is to be maintained. Some monitoring techniques are complex, costly and invasive, and the additional information they provide may not be very great; it is thus imperative that clear indications for these procedures be defined if a waste of money and manpower is to be avoided and the risk of patient injury minimized. In this article several monitoring techniques concerned with central vascular volume arc discussed in the hope of providing guidelines for their use and of stimulating further interest in this problem. We believe that optimum results are obtained in the care of critically ill patients if efforts are directed to maintaining the internal environment in a state as near normal as possible. This cannot be done without the use of basic monitoring procedures. However, there is a real risk of complex procedures becoming an end in themselves, and we have attempted to indicate the situations in which we consider these monitoring techniques to be useful. Doubt has been voiced about all of the procedures discussed, both from a community economic viewpoint and from an unnecessary patient-risk point of view. We consider that the wide use of chest radiography and plasma protein estimations is relatively harmless, and that they are extremely useful tools. CVP measurement, pulmonary artery pressure measurement, blood volume estimation and cardiac output measurement are each useful in specific circumstances. At present the indications for CVP measurement are still thought to be wide, whereas the indications for the other three monitoring procedures are in our opinion narrow but definite. We believe that the cost to the patient and to the community is justified in those special circumstances. The management in a regional unit of 158 patients with thoracic trauma resulting in respiratory failure is described. Emphasis is placed on the need for accurate diagnosis of intraabdominal trauma in the presence of chest injury. Peritoneal tap is advocated, both to avoid unnecessary laparotomy and to diagnose haemoperitoneum when intraabdominal signs are obscured by those of the thoracic injury. Following laparotomy on a patient with significant pulmonary trauma, artificial ventilation is necessary for some days, but when the trauma chiefly involves the chest, an opportunity exists to manage the patient by pain relief alone. Forty-five patients suffering respiratory failure following injury to the chest and abdomen were managed, and 12 died, while 35 needed artificial ventilation. The defective use of radiology by the clinician and radiologist is prevalent. The causes and consequences are discussed regarding carcinoma of the cardiac end of the stomach. Present-day results are so poor that a new approach is suggested. A comprehensive set of films should be secured to show adequately all regions of the stomach, each region in two planes, and the gastroenterologist, as well as the radiologist, should set their mind to the interpretation of these films. Such methods, applied in other branches of surgery and medicine, have led to an increase in diagnostic efficiency. The failure of the cardiac end to balloon when the patient is supine, with the stomach as full as possible, is a sign of advanced carcinoma. Attention is drawn to this, not as a new sign, but as one that is frequently overlooked. A technique has been suggested in the hope of securing the detection of growths when they are as large as a cherry, to supplement the present technique, which often overlooks them even when they are the size of a cricket ball. These supplementary views are like all other methods in medicine. They have their fallacies and their difficulties. But they should not be discarded on this account. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.