Situs inversus totalis is a rare defect which can present difficulties in the management in laparoscopic surgery due to the mirror-image anatomy. Herein, we report a patient with situs inversus totalis and super-super-obesity (BMI 76 kg/m2). We performed successful laparoscopic sleeve gastrectomy. Technical details of this operation, with situs inversus totalis, are presented. There were no major difficulties compared to patients with usual anatomy. There are potential diseases associated with situs inversus and obesity; therefore, a careful investigation, including a chest x-ray and cardiac and abdominal ultrasounds should be performed before surgery. Sleeve gastrectomy is an adequate procedure in super-super-obese patients with situs inversus totalis.
Our relaxant-sparing approach did not increase the incidence of poor conditions of intubation nor laryngeal symptoms. However, excellent conditions occurred more frequently in the relaxant group. A more flexible approach to the issue of the need for neuromuscular blockade prior to intubation is proposed.
Anaphylactic reactions are a common complication of anesthesia, most often related to the use of muscle relaxants.1 The intensity varies from mild clinical manifestations to severe anaphylactic shock and death. 2 With increased public awareness and the improvement in the detection and diagnosis of such adverse events, an increased frequency has been reported in most developed countries. 3In France, a recent survey estimated the incidence of anaphylactic reactions to be as high as one amongst 6,500 anesthetic procedures when a muscle relaxant is used.1 Approximately four individuals per 100 population (2.5 million) receive muscle relaxants during anesthesia every year. 4 These data allow us to postulate that among the French population alone (60 million people), 350 patients every year will develop a muscle relaxant mediated anaphylactic reaction. Similarly, thousands of patients all over the world will experience similar adverse events. Risk reduction requires that the use of muscle relaxants be limited inasmuch as possible since anaphylaxis may occur in patients with or without a previous history of allergy. 1To date, there are two main indications for muscle relaxants during anesthesia for elective surgery. The first involves the anesthetic procedure itself, i.e., tracheal intubation, while the second relates to the surgical procedure. Muscular relaxation facilitates airway management, access to the surgical site, closure of the abdominal wall and avoids inopportune movements. However, muscle relaxants are no longer mandatory.There is now evidence that the development of new hypnotic drugs has changed airway management and allows tracheal intubation without the need for muscle relaxants in a selected population.5 From a surgical point of view, abdominal and thoracic procedures usually require muscular relaxation but, on the other hand, numerous peripheral surgical procedures such as lower abdominal and limb operations do not require the use of curare.While recent data show that it is possible to intubate the trachea without resorting to muscle relaxants, the topic remains controversial. Intubating habits vary both locally and internationally. It has been suggested that muscle relaxants decrease pharyngeal and laryngeal trauma secondary to intubation.5 As a result, several anesthesiologists are reluctant to curtail muscle relaxation for intubation. In 1996, in France, only 16% of anesthetics requiring tracheal intubation were conducted without the use of muscle relaxants. 4 This puts us in a delicate situation. As anesthesiologists, we use a class of drugs, muscle relaxants, known to mediate anaphylaxis with potentially lifethreatening consequences whereas, on the other hand, there is no more doubt that we are able to avoid these drugs in many situations.Should we still widely use muscle relaxants or should we restrict their prescription? Patient safety during anesthesia requires us to take into account all risks, even those that may have been underestimated in the past.
Objectif : L'anesthésie s'exerce volontiers en équipe, faisant intervenir pour un même patient, plusieurs praticiens au cours de son séjour hospitalier. L'objectif de ce travail était de recueillir l'opinion des patients sur ce sujet.Eléments cliniques : Nous avons interrogé 912 patients consé-cutifs (âge: 51 ± 16 ans; sexe: H 58%) à la fin de la consultation d'anesthésie, sur leur préférence éventuelle pour l'anesthésiolo-giste du bloc opératoire. Cette question était posée par l'infirmière et en l'absence du médecin consultant afin d'éviter une réponse "induite ou polie" en faveur de celui-ci. Avant la fin de l'hospitalisation, le sentiment des patients concernant le fait de ne pas avoir été pris en charge par le même anesthésiologiste, lorsque c'était le cas, était réévalué. Finalement, l'identité des praticiens ayant participé à leur prise en charge était demandée.
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