Department of Surgery, University of New Mexico Hospital, Albuquerque, NM.

ABSTRACT

We report a case of a 21-year-old male who presented with adult-onset dysphagia after previous Nissen fundoplication initially created at age 10.5 months. The patient first presented one year ago to a different hospital, where he underwent extensive workup for his symptomatology. Physiologic tests performed were esophagogastroduodenoscopy (EGD), ab- dominal ultrasound, hepatobiliary iminodiacetic acid scan, esophageal manometry, and lactulose breath test. The EGD identified stricture at the level of the gastroesophageal junction. The other studies did not reveal other physiologic causes for his symptoms. The patient then presented to our institution, at which time a repeat EGD showed evidence of tight Nissen fundoplication. The patient subsequently underwent laparoscopic exploration, which revealed that the fundopli- cation had was partially disrupted, herniated, and twisted causing a long-segment distal stricture. To alleviate the patient’s presenting symptom of dysphagia as well as prevent possible future reflux, it was decided to convert repair the hernia and revise the Nissen into a partial fundoplication. This was successfully accomplished laparoscopically with sub- sequent resolution of the patient’s symptoms.

Key Words: Pediatric GERD, Nissen fundoplication, Toupet fundoplication, Dysphagia.

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.

Colorectal Surgery Department, Hospital Central Militar, México City, México (Dr. M. Gurieb-Trueba)
Advanced Endoscopy Department, Hospital Central Militar, México City, México (Dr. V. M. Rivera-Méndez)
Hospital San Ángel Inn Chapultepec, México City, México (Dr. J. C. Sánchez-Robbles)

ABSTRACT

Colorectal cancer prevention relies on effective screening through colonoscopy and polypectomy. Several techniques and methods have been described to manage complex colonic polyps such as the ones that are endoscopically unresectable. Across time, we have been able to perform less invasive techniques that include different types of colonic resections, ranging from partial thickness, full-thickness and, segmental colectomies, however, none has proven to be the treatment of choice for these lesions. The technique presented here is an attractive alternative to segmental colectomy using a robotic platform to perform a full-thickness resection.

Key Words: Robotic surgery, Combined approach, Polyp, Colon, Colonoscopy, Colon cancer, Minimally invasive surgery.

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Geisinger Wyoming Valley General Surgery Residency Program, Wilkes-Barre, PA (all authors).

ABSTRACT

Introduction: A parastomal hernia (PSH) is an abnormal herniation of an intra-abdominal organ or other tissue through an intentionally created fascial defect at an ostomy site. PSHs commonly involve reducible mobile segments of omentum, intra-abdominal fat, and bowel. However, PSHs may rarely involve fixed intra-abdominal organs such as the stomach.

Case Description: A 68-year-old female underwent emergent Hartmann procedure for Hinchey III diverticulitis and subsequently developed a large reducible parastomal hernia. She was scheduled for an elective laparoscopic colostomy reversal. Prior to her scheduled reversal, the patient presented to the ED with anorexia, lack of colostomy output, emesis, and pain localized to her left lower quadrant. She was found to have gastric outlet obstruction secondary to herniation of the stomach through the left lower quadrant colostomy site. The patient was admitted and treated conservatively with resolution of her symptoms, but due to the high likelihood of recurrence, the decision was made to proceed with laparoscopic Hartmann colostomy reversal with coloproctostomy and primary clo- sure of the fascia without mesh.

Conclusion: The contents of a PSH can become incarcerated causing obstruction, strangulation, necrosis and even perforation over time. Fortunately, in this case, herniation of the stomach was recognized early. The patient underwent repair of the hernia defect in order to prevent recurrence of gastric herniation and its potential detrimental complications. The decision regarding the technical aspects of ostomy reversal in terms of mesh selection require further study. In our case, mesh was not used due to patient-specific factors and comorbidities.

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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.

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Department of Clinical Education, Taipei Tzu Chi Hospital, Buddhist Tzu, Chi Medical Foundation, New Taipei, Taiwan (Dr. Y-H Lin)
Department of Radiology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi, Medical Foundation, Chiayi, Taiwan (Dr. C-W Lin)
Department of Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan (Dr. W-Y Yin) School of Medicine, Tzu Chi University, Hualien, Taiwan (Drs. Y-H Lin, C-W Lin, and W-Y Yin)

ABSTRACT

We report a case of bile leaks post-laparoscopic cholecystectomy (LC) with initial treatment failure by common bile duct stent insertion. The injury of a subvesical duct running from gallbladder fossa toward an area of fluid accumulation that was not revealed by computed tomography and endoscopic retrograde cholangiopancreatography previously, was even- tually found by magnetic resonance cholangiopancreatography (MRCP) and proved to be the cause of bile leak. Also, several tiny branches in the right liver instead of a main trunk and another subvesical duct draining into the common bile hepatic duct was noted. These anatomic variations were scarcely reported, especially by MRCP.
The aim of this case report is to discuss the link between biliary tree anomaly and bile leak due to bile duct injury during LC in our experience treating one patient. Also, we review related literature to understand more on prevention or man- agement of subvesical duct injury.

Key Words: Subvesical duct injury, Laparoscopic cholecystectomy, Bile leak, Biliary tree anomaly.

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Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China (all authors).

ABSTRACT

Introduction: The occurrence of pregnancy with Cushing syndrome (CS) is rare but with high risks, posing a great challenge to the clinical diagnosis and treatment of the disease.

Case Description: From Aug 2016 to Aug 2019, we admitted two pregnant women with CS caused by adrenal tumors. After multidisciplinary consultation, they underwent emergency Cesarean section because of heart failure and severe hypoxemia, and finally delivered a living baby after adjuvant therapy. Both patients underwent retroperitoneal laparoscopic adrenectomy (RLA) 2.6 and 1.5 months postpartum to have the adrenal tumors removed successfully. The post- operative pathology confirmed the adrenal tumor as adrenocortical adenoma. Partial hormone replacement therapy was initiated postoperatively and withdrawn uneventfully 1 year after RLA in both patients, and both patients have recovered well.

Conclusion: It is difficult to find CS in early pregnancy, and when it is detected in late pregnancy, it often poses a great risk because it is necessary to consider the safety of both mother and fetus, which requires multidisciplinary coordination and cooperation to positively adjust the cardiopulmonary function and internal environment after Cesarean section, knowing that timely RLA to remove the adrenocortical adenoma can effectively cure CS.

Key Words: Pregnancy, Cushing syndrome, Adrenal tumor, Heart failure, Hypertension.

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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.

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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.

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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.

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