The increased intraperitoneal pressure necessary to perform laparoscopic operations reduces substantially the portal venous flow. The extent of the volume flow reduction is related to the level of intraperitoneal pressure. This reduction of flow may depress the hepatic reticular endothelial function (possibly enhancing tumor cell spread). In contrast, the reduced portal flow may enhance cryoablative effect during laparoscopic cryosurgery for metastatic liver disease by diminishing the heat sink effect. These findings suggest the need for a selective policy, low pressure or gas-less techniques to positive-pressure interventions, during laparoscopic surgery in accordance with the disease and the therapeutic intent.

Netherlands Trial Registry Identifier: NTR2249.

This preliminary study has shown that segmental spinal anaesthesia can be used successfully and effectively for laparoscopic surgery in healthy patients. However, the use of an anaesthetic technique involving needle insertion into the vertebral canal above the level of termination of the spinal cord requires great caution and should be restricted in application until much larger numbers of patients have been studied.

Occasionally patients awaiting heart or lung transplant because of terminal disease require other types of surgery, but present significant challenges to the anaesthetist because of impaired organ function. Regional anaesthesia may have much to offer such patients and we here report one who underwent successfully a laparoscopic cholecystectomy under segmental subarachnoid (spinal) anaesthesia performed at the low thoracic level. The anatomical and physiological consequences of such a technique are discussed.

Objectives To determine the eBcacy and costs of extraureter in 24 patients and in the lower ureter in 80. The outcome was assessed by stone-free rates, corporeal shock-wave lithotripsy (ESWL) compared with ureteroscopy (URS) in the treatment of mid-and re-treatment rates, time to become stone-free, complications and costs. lower ureteric calculi. Patients and methods The records of patients treatedResults ESWL for mid-and lower ureteric calculi resulted in a success rate of 90% and 81%, respectively, primarily by ESWL and URS were analysed retrospectively. Treatment with ESWL included 63 patients (42 compared with 96% and 99% for URS. However, patients treated with URS were stone-free within men and 21 women, mean age 52 years, range 23-78, 19 mid-and 44 lower ureteric calculi). All 2 days, whereas patients in the ESWL group required up to 4 months. The best results for ESWL were patients received 4000 shock waves at a mean energy setting of 18.1 kV. URS was used in 105 patients, achieved with stones of <50 mm2. The costs of URS were higher than those for ESWL. with a 7.2 F miniscope or the 7.1 F flexible scope. Stones were fragmented with a pulsed-dye laser lithoConclusions ESWL provides a noninvasive, simple and safe option for the management of mid-and lower tripter at 504 nm and a power of up to 130 mJ (mean 53 mJ) using a 200 or 320 mm fibre. All ureteroscopies ureteric calculi, provided that the stones are <50 mm2; larger stones are best treated by URS. were performed with the patient under general (n= 17) or spinal (n=87) anaesthesia in a mean treatment Keywords Ureteric calculi, extracorporeal shock-wave lithotripsy, ureteroscopy duration of 34 min. Stones were located in the mid-URS, and controversy about the optimal treatment