Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA (all authors).

ABSTRACT

Introduction: There is a lack of information in the literature regarding acute appendicitis in the setting of acute diverticulitis. As acute appendicitis and acute diverticulitis together make up most community-acquired complicated intra-abdominal infections, it is very likely that the provider will encounter them in the patient presenting with abdominal pain.

Case Description: We report a patient with recurrent diverticulitis who carried a codiagnosis of acute appendicitis; the appendix was laparoscopically removed, and her diverticulitis flare was managed nonoperatively.

Discussion: In the patient with a history of diverticulitis presenting with abdominal pain, a high index of suspicion for other coexisting intra-abdominal pathology must be maintained. Computed tomography offers a powerful tool to aid in diagnosis.

Key Words: Appendicitis, Diverticulitis, Laparoscopy, Surgery.

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Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal (all authors). ICVS/3B’s—PT Government Associate Laboratory, Braga/Guimarães, Portugal (all authors). Department of Obstetrics and Gynecology, Centro Hospitalar do Porto, Porto, Portugal (Dr Ferreira). Department of Obstetrics and Gynecology, Hospital de Braga, Braga, Portugal (Dr Nogueira-Silva). Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal (Dr Correia-Pinto).

ABSTRACT

Background: The sentinel lymph node (SLN) concept might minimize surgical aggressiveness in gynecological oncology, namely in cervical and endometrial malignancies. Therefore, we assessed the feasibility of SLN identification, dissection, and harvesting by using minilaparoscopic surgical instruments in an animal model. We compared the minilaparoscopic approach, which is known to bring important advantages, with the use of conventional laparoscopic instruments.

Methods: Two groups of 7 female pigs were enrolled in this experiment that was performed by the same surgical team. In group A, all animals were approached by a similar minilaparoscopic surgical instrumentation, namely a 5-mm 30° endoscope (supraumbilical port) and 3 ancillary 3.5-mm trocars. In group B, a 5-mm conventional laparoscopic instrument set was used. The patent blue (4.0 mL) was injected on the paracervical region. The time for SLN coloring, identification, localization, dissection, and excision, as well as complications were recorded. The sealing of the lymphatic vessels was observed in the 2 groups. During this experiment, and for the both groups, the Trendelenburg position was kept the same, as well as the carbon dioxide–pneumoperitoneum pressure. Finally, a laparotomy was then performed to evaluate whether any stained SLN still remained.

Results: All endoscopic procedures were performed without major complications. SLN were identified and excised in all animals in both groups. The SLN localization varied between animals from external iliac to preaortic regions. The surgical times, from skin incision to SLN removal, was 28.4 ± 5.6 minutes for minilaparoscopy and 25.3 ± 6.8 minutes for conventional laparoscopy (P=.36). In group B, 1 stained SLN remained and was only detected by laparotomy.

Conclusions: We confirmed the feasibility of the minilaparoscopic surgical approach for identification, dissection, and excision of SLN, as well as for sealing the lymphatic vessels that supply the nodes. This procedure might be considered a potentially better alternative to reduce morbidity during staging procedures for gynecological malignancies.

Key Words: Gynecology, Instrumentation, Malignancy, Minilaparoscopy, Sentinel lymph node, Surgery

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University of Central Florida College of Medicine, Orlando, FL, USA (Drs. Dobradin, LePane). Winter Park Memorial Hospital, Winter Park, FL, USA (Drs. Dobradin, Mansilla, LePane). St. Matthew’s University, School of Medicine West Bay, Grand Cayman, KY (Ms. Henson).

ABSTRACT

Introduction: Small-bowel massive bleeding presents a complex diagnostic and therapeutic problem. Angiography can be used for localization and embolization of the overt gastrointestinal bleeding site. Because of the complex anastomotic network of blood vessels supplying the small intestine, precise identification is complicated and surgical resection of the bleeding site is difficult. We describe angiography-directed preoperative microcoil placement for a localization of the bleeding site using intraoperative fluoroscopy during laparoscopic small-bowel resection.

Case Description: The described method was used successfully in a 58-year-old woman who was started on a chemotherapy regimen of idarubicin and cytarabine, which has been reported to cause small-bowel hemorrhage, occasionally resulting in fatal outcomes. Overt small intestinal bleeding developed due to enteritis that was unresponsive to conservative therapy and required massive blood transfusions.

Discussion: Many modalities are available for diagnosing and treating obscure small intestinal bleeding when only few of them are suitable for overt bleeding management. We offer an innovative approach that may successfully service the void of an effective technique to treat massive small intestinal bleeding resistant to conservative treatment.

Key Words: Overt gastrointestinal bleeding, Angiography, Surgery, Microcoil, Small intestine.

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