ABSTRACT

Background and Objectives: Less than 300 cases of a De Garengeot’s hernia have been published. This rare femoral hernia with the vermiform appendix included appears almost exclusively on the right side, mainly in females, and it gen- erally debuts as an incarcerated femoral hernia. Although most of the times there is a concomitant appendicitis, clinical signs of peritonitis are absent. The wide use of radiologic exams has not favored its preoperative diagnosis, but been usually found incidentally during a surgical emergency. The best surgical approach to a De Garengeot’s hernia is not totally defined and many critical questions still remain unanswered. Open surgery is considered the standard treatment procedure, but since the emergence of laparoscopy for incarcerated hernias, this is certainly an option.

Methods: We report the successful laparoscopic management of an 83-year-old woman who had been operated on her right inguinal hernia, with a Rutkow-Robbins’ technique, 4 months earlier. She had noticed the protrusion of a lump in her right inguinal region for 2 months. Radiological studies were not conclusive. With a miss diagnosis of a recurrent incarcerated inguinal hernia, a minimal invasive endoscopic approach was performed. A representative case of this fully laparoscopic TAPP procedure is presented.

Results: The patient made an uninterrupted recovery. She left the hospital the day after in a stable condition and has enjoyed good health since.

Conclusion: A fully laparoscopic TAPP approach seems perfectly safe and feasible to treat this entity, and could be con- sidered the first line alternative when enough expertise is available.

Key Words: De Garengeot’s Hernia, TAAP, Laparoscopic Hernioplasty, Appendix, Femoral Hernia.

Download (PDF, Unknown)

The post Appendix-Sparing Transabdominal Preperitoneal Laparoscopic Hernioplasty for a De Garengeot’s Hernia. Video Demonstration first appeared on CRSLS.

Department of Surgery, Damsoyu Hospital, Seoul, Republic of Korea.

ABSTRACT

Background and Objectives: In patients with inguinal hernias who have undergone radical prostatectomy, dissecting the medial preperitoneal space is difficult because of the presence of fibrotic scars. It is also difficult to guarantee sufficient space for mesh implantation. We added laparoscopic iliopubic tract repair (IPTR) to transabdominal preperitoneal (TAPP) hernioplasty, and evaluated this for the treatment of inguinal hernias after radical prostatectomy

Methods: This retrospective study included 29 male patients with inguinal hernias after radical prostatectomy who underwent TAPP hernioplasty between January 1, 2015 and October 31, 2018. Laparoscopic IPTR was performed first, followed by TAPP hernioplasty.

Results: All patients had an indirect inguinal hernia. The mean time from radical prostatectomy to TAPP hernioplasty was 2.1 years (range, 0.3–11 years). In one patient, the peritoneal flap was insufficient, and the operation was performed using a dual-layer mesh. All other patients underwent conventional TAPP hernioplasty. The mean operation time was 42 min (range, 30–50 min), and the mean duration until return to normal activities was 8.4 days. There were two minor postoperative complications (one hematoma and one seroma). The mean follow-up period was 45.8614.0months (range, 22–67 months), and chronic pain or recurrence was not observed.

Conclusion: Adding laparoscopic IPTR to TAPP hernioplasty in patients with a history of radical prostatectomy is feasi- ble and safe, with a low risk of chronic pain and recurrence.

Key Words: Inguinal hernia, Hernioplasty, Prostatectomy, Laparoscopy.

Download (PDF, Unknown)

The post Laparoscopic Iliopubic Tract Repair with Transabdominal Preperitoneal Hernioplasty after Radical Prostatectomy first appeared on CRSLS.

Department of Medicine, Division of Gastroenterology and Hepatobiliary Diseases, New York Medical College, Westchester Medical Center, Valhalla, New York (Drs. Olivier-Cabrera, Tewari, Gollapudi).
Department of Surgery, Division of Pediatric Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York (Dr. Stringel).

ABSTRACT

Introduction: Symptomatic intraperitoneal collections in difficult anatomical locations can present a management chal- lenge. Even after access and drainage are accomplished, reaccumulation of thick material inside the cavity can continue to cause problems. The use of fibrinolytic agents has been reported to facilitate drainage of thick material, hematomas, purulence, and fibrin.

Case Description: We present a 16-year-old male with idiopathic thrombocytopenic purpura who developed a symp- tomatic intraperitoneal hematoma with dimensions of 5
6
6.7 cm, abutting the spleen, pancreas, and left kidney, caused by blunt trauma. Interventional radiology could not drain the cyst because of the location. Initial drainage was done with endoscopic ultrasound (EUS)-guided placement of a lumen apposing self-expandable 1.5 cm wide metal stent designed for cystogastrostomy. The patient continued to be febrile despite saline irrigation used in the initial procedure. Two endoscopic sessions employing thrombolytic agents (4 mg of tissue plasminogen activator and 5 mg of deoxyribonuclease) instillation into the collection at weekly intervals were used. The stent was removed after 8 weeks with complete resolution of the collection. He was discharged home and remained asymptomatic after 1 year of follow-up.

Conclusion: The present case demonstrates the successful and safe use of EUS-guided transgastric drainage in conjunc- tion with fibrinolytic/thrombolytic agents to facilitate dissolution of thickened internal debris, especially in collections with a capsule when mechanical debridement can lead to spillage of infected material and cause generalized peritonitis. To the best of our knowledge, this is the first report of endoscopic drainage utilizing thrombolytic agents.

Key Words: Endoscopic drainage; Intraperitoneal hematoma; Transgastric drainage; Fibrinolytic agents; Thrombolytic agents.

Download (PDF, Unknown)

The post Endoscopic Drainage of a Symptomatic Intraperitoneal Hematoma with a Metal Stent and Intracavitary Thrombolytics first appeared on CRSLS.

Service of General Surgery, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil. Rua Ramiro Barcelos, 2350 – Santa Cecilia, Porto Alegre – RS, 90035-007 (Drs Militz, Corleta, Cavazzola and Messrs Mossman and Pretto).
Service of Digestive Surgery, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil. Rua Ramiro Barcelos, 2350 – Santa Cecilia, Porto Alegre – RS, 90035-007 (Dr Osvaldt).
Universidade do Sul de Santa Catarina, Palho̤a, Santa Catarina, Brazil. Avenida Pedra Branca, 25 РPedra Branca, Palho̤a РSC, 88137-270 (Dr Militz).

ABSTRACT

Gastrointestinal stromal tumors (GST) account for less than 1% of the total tumors of the gastrointestinal tract. Data suggests that 50–60% of these tumors are located within the stomach and 10–20% in the small bowel. The esophagus involvement is extremely rare, accounting for less than 5% of all GST. This explains the scarcity of clinicopathological data and lack of clear recommendations regarding surgical management of this disease. Surgery as the first line therapy has been associated with better outcomes such as disease control, increased survival, and complete cure.
We present a case of a 63-year-old woman who was referred to the General Surgery Department of the Hospital de Clínicas de Porto Alegre due to dysphagia for solid food with 5years of evolution. Upper gastrointestinal endoscopy revealed an ulcerated and stenosing lesion of the middle third of the esophagus extending from 25 cm to 33 cm from the upper dental arch. Lesion biopsies confirmed the diagnosis of esophageal GST. She was submitted to neoadjuvance with tyrosine kinase inhibitor and a robotic esophagectomy in prone position was performed.

Key Words: Esophagus; Gastrointestinal stromal tumors; Esophagectomy; Robotic esophagectomy.

Download (PDF, Unknown)

The post Robotic Esophagectomy for Esophageal Gastrointestinal Stromal Tumor first appeared on CRSLS.

Houston Methodist Hospital, Houston, USA (all authors).

ABSTRACT

Background: In this case report, a patient had complicated marginal ulcer perforation that led to gastrointestinal tract discontinuity with future plan for reversal. However in this novel case, the patient had spontaneous continuity, which prevented another major, complicated surgery.

Methods: A 59 year-old female who underwent exploratory laparotomy due to a very complicated perforated marginal ulcer that failed multiple medical/endoscopic treatments. Patient was left in discontinuity due to tissue friability, and was left with gastric tube to gastric pouch and gastric remnant, with plans to do anastomosis in three to six months.

Results: There was a spontaneous fistula that formed between the prior gastric pouch and gastric remnant with two gastric tubes found within gastric remnant.

Conclusion: Due to spontaneous gastrogastric fistulalization, or spontaneous gastric bypass reversal, our patient did not require another major complicated surgery.

Key Words: Marginal ulcer perforation, Discontinuity, Spontaneous reconstitution of gastrointestinal tract.

Download (PDF, Unknown)

The post Spontaneous Gastrogastric Fistulalization After Being Left in Discontinuity of Proximal Gastric Pouch and Roux Limb Due to Catastrophic Gastrojejunal Marginal Ulcer Perforation first appeared on CRSLS.

Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Gangaram Hospital, New Delhi, India (Drs. Bindal, Sethi, Khetan, Kalhan, John, Dadhich).
Department of Minimally Invasive and Gastrosurgery, Apollo Gleneagles Hospital, Kolkata, India (Dr. Ramana).

ABSTRACT

Introduction: The enhanced-view totally extraperitoneal (eTEP) approach is increasingly being used to tackle large ventral and incisional hernias. We are presenting a case of robot-assisted eTEP with unilateral transversus abdominis release (TAR) without crossover through all midline ports for an open appendectomy site boundary hernia.

Materials and Methods: Patient presented with a large incisional hernia at the open appendectomy site. Contrast- enhanced computed tomography revealed disruption of linea semilunaris on right side, with a 12-cm defect having large bowel and omentum as content of hernia sac. We planned a unilateral eTEP approach without crossover. We performed a diagnostic laparoscopy to inspect the contents of the hernia sac by inserting a 5-mm port in the left subcostal region. The peritoneal cavity was deflated, and access was made in the retro-rectus space via right subcostal region using optical entry. Three ports were inserted on the right side on linea alba, in the retro-rectus space. Robotic system was docked, eTEP space developed, and right-sided TAR was done saving the neurovascular bundles. The posterior rectus sheath complex and anterior defect was closed using barbed sutures. A 20 􏰀 25-cm medium weight polypropylene mesh was placed.

Result: The operative time was 160 min and estimated blood loss was 50 mL. Postoperative stay in the hospital was uneventful and the patient was discharged on postoperative day 2. She is doing well at 9 mo followup. This case was unique as it was a unilateral eTEP/TAR without crossover, using robotic approach. We could not find any published report of similar approach of posterior component separation using robot.

Conclusion: Robotic eTEP/TAR is a safe and feasible approach to tackle large incisional hernias. Robotic system provides distinct advantages in dissection, identifying the planes and suturing in eTEP space.

Key Words: hernia, ventral hernia, incisional hernia, robotic hernia surgery, extended-view totally extraperitoneal, eTEP, eRS, eTAR, AWR, abdominal wall reconstruction.

Download (PDF, Unknown)

The post Robotic Extended-View Totally Extraperitoneal Transversus Abdominis Release (eTEP/TAR) Without Crossover for a Large Right Boundary Incisional Hernia first appeared on CRSLS.

Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM (Drs. Kamya, Zimmermann, and Phuoc). Department of Pathology, University of New Mexico School Medicine, Albuquerque, NM (Dr. Hanson).

ABSTRACT

We report a case of a 58-y-old male with a metachronous abdominal wall metastasis secondary to colorectal cancer. The patient initially presented 2 y ago at an outside facility with stage IV (T4, N0, M1) sigmoid colon cancer with liver metastasis. Fine needle aspiration (FNA) was performed of the liver masses, located in segment 5, inferior segment 4B, and segment 2 and ranging between 1 and 3 cm in size. The patient subsequently underwent laparoscopic sigmoid colon resection with end colostomy creation. Following this, adjuvant chemotherapy was administered with five cycles of FOLFOX. Interval computed tomography (CT) scan following chemotherapy demonstrated a decrease in size of the larger liver masses. At our institution, an open total left hepatic lobectomy (hepatic segments 2, 3, and 4) and a partial right hepatectomy of hepatic segment 5 were performed. Twelve further cycles of adjuvant chemotherapy were then performed. One year after the sigmoid resection, robot-assisted colostomy closure with end-to-end, double-stapled coloproctostomy was then performed. A subsequent CT identified a small right liver lesion consistent with metastasis, and as such the patient underwent further cycles of chemotherapy. Following these cycles of chemotherapy, positron emission tomography/CT demonstrated a resolution of the liver recurrence; however, a hypermetabolic lesion at the former site of colostomy within left anterior rectus musculature was evident. This was confirmed on core needle biopsy to be adenocarcinoma of colon primary. Robotic-assisted resection of the abdominal wall metastasis was successfully performed.

Key Words: colorectal cancer recurrence, abdominal wall metastasis, metastectomy, robotic.

Download (PDF, Unknown)

The post Robotic-Assisted Resection of an Abdominal Wall Colorectal Cancer Metastasis first appeared on CRSLS.

Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey (Drs. Mackowsky and Borao).
Department of Surgery, Hackensack University Medical Center, Hackensack, New Jersey (Drs. Hadjiloucas and Lira).

ABSTRACT

Background: Concurrent laparoscopic paraesophageal repair with colectomy has yet to be described in the literature.

Case Description: An 88-y-old male with shortness of breath and rectal bleeding presented to the emergency depart- ment. Workup ultimately revealed a nonobstructing ascending colon mass within the sac of type IV paraesophageal hernia. The decision was made to proceed with laparoscopic colectomy with concurrent paraesophageal hernia repair.

Conclusion: To reduce overall operative time and optimize recovery, the decision was made to perform both operations synchronously. The patient suffered no intraoperative or postoperative complications and experienced a full and timely recovery. To the best of our knowledge, simultaneous colon resection with paraesophageal hernia repair has not been described in the literature. Despite the inherent high risk, performing both procedures in a single operation helped to decrease the patient’s anesthesia time and overall recovery time as well as risks of reoperation.

Key Words: paraesophageal hernia repair, colectomy, adenocarcinoma.

Download (PDF, Unknown)

The post Simultaneous Repair of Paraesophageal Hernia and Colectomy for Colon Cancer first appeared on CRSLS.

Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, New York (Ms. Gogel and Dr. Zaveri). Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York (Dr Dickstein). Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York (Dr. Nguyen, Zhang, Divino, and Chin). Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York (Dr. Badani).

ABSTRACT

Introduction: Splenic rupture can be classified as traumatic, pathologic, or spontaneous. Spontaneous splenic rupture is rare, and accounts for only 1% of cases. Most cases of spontaneous splenic rupture involve a histopathologically abnormal spleen, but in rare cases, rupture of the spleen can occur in the absence of underlying disease or trauma. We present a case of delayed spontaneous splenic rupture in the postoperative setting following a partial nephrectomy.

Case Description: A 54-y-old man presented with abdominal pain, dysuria, fever, and chills 1 week after a robotic left partial nephrectomy. An initial computed tomography scan showed no evidence of splenic injury, and he was admitted for suspected pyelonephritis. A computed tomography scan was obtained 4 d later for worsening pain and fever and revealed a 14-cm subcapsular hematoma of the spleen extending to the gastrohepatic ligament. He underwent an emergent angiogram and embolization of an actively bleeding splenic artery and inferior phrenic artery. A second embolization was required 2 d later to control ongoing bleeding. He then developed increased abdominal pain with nausea, vomiting, and continued leukocytosis secondary to a completely infarcted and necrotic spleen. A laparoscopic, hand-assisted splenectomy was performed successfully, and he was eventually discharged in stable condition.

Conclusion: Spontaneous splenic rupture is extremely rare, particularly in the postoperative setting. It is possible that some of these cases are in fact secondary to occult trauma to the spleen during surgery. Prompt diagnosis and management, often with emergent splenectomy, is critical in these cases. Minimally invasive surgery is a feasible option for splenic resection in cases of spontaneous splenic rupture.

Key Words: splenic rupture, splenectomy, nephrectomy.

Download (PDF, Unknown)

The post Delayed Splenic Rupture after Robotic Partial Nephrectomy first appeared on CRSLS.

Department of Surgery, University of Miyazaki Faculty of Medicine, Kiyotake, Miyazaki City, Miyazaki, Japan (Drs Kai, Ikeda, Ichihara, Hamada, Nagatomo, and Nanashima).
Department of Obstetrics and Gynecology, University of Miyazaki Faculty of Medicine, Kiyotake, Miyazaki City, Miyazaki, Japan (Drs Matsuzawa, Ushijima, Furukawa, and Sameshima).

ABSTRACT

Introduction: Acute appendicitis is the most common general surgical problem during pregnancy. Laparoscopic appendectomy has been gaining widespread popularity and has been accepted as a minimally invasive surgery based on evidence for its use in appendicitis in pregnant patients. However, the gravid uterus in the third trimester and the frequent suction required for abscess drainage make the working space intractable.

Case Description: We report a case in which an AirSeal intelligent flow system (ASIFS) (CONMED Corporation, Utica, NY, USA) was useful for laparoscopic appendectomy and abscess drainage for perforated appendicitis in a 31-wk pregnant patient. ASIFS allowed successful maintenance of a working space, thus making it possible to excise the appendix at its base with double ligation and effectively drain the abscess with no maternal and fetal complications. To our knowledge, there have been no reports of the use of ASIFS in a pregnant patient. A past study reported that ASIFS could induce hypothermia compared with a conventional CO2 supply tube in patients. Although intraoperative hypo- thermia did not occur in our patient, it would be prudent to carefully avoid frequent suctioning in the short term and to warm the patient intraoperatively because maternal and fetal bodies are susceptible to change in hemodynamics.

Conclusion: Surgeons should consider the use of ASIFS before deciding to convert from laparoscopic appendectomy to an open procedure in pregnant patients.

Key Words: laparoscopic appendectomy, perforated appendectomy, third trimester, AirSeal intelligent flow system.

Download (PDF, Unknown)

The post AirSeal was Useful in Laparoscopic Surgery for Perforated Appendicitis During Pregnancy first appeared on CRSLS.