Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis: Port Placement and Dissection Techniques.

BACKGROUND Situs inversus is a rare congenital condition. Since 1991, more than 60 cases of laparoscopic cholecystectomy have been reported in patients with situs inversus. There are many different port placement techniques depending on the surgeon's preference. The fact that some of the critical dissection is easier performed by the left hand poses technical difficulty for right-handed surgeons. CASE REPORT A 56-year-old woman with known situs inversus totalis and extensive past surgical history presented with acute cholecystitis. A Veress needle was used to enter the abdomen at Palmer's point. Visiport was used to place the first 5-mm port at the left mid-clavicular line. The dissection was performed in a mirror image to the usual dissection through the epigastric port. CONCLUSIONS There have been several techniques described in the literature to facilitate the dissection in laparoscopic cholecystectomy in patients with situs inversus totalis. We argue that the first port should be placed at the mid-clavicular line with Visiport. The other ports should be placed in mirror image of the normally placed ports, including a 12-mm epigastric port, 5-mm or 11-mm paraumbilical port, and 5-mm port at the left anterior axillary line. For dissection, we argue that it is preferable to have 2 assistants with 1 retracting the gallbladder and the other holding the camera. This allows the primary surgeon to use the dominant hand during critical dissection in this unfamiliar anatomy.

The diagnosis and staging of pancreatic cancer: A comparison of endoscopic ultrasound and computed tomography with pancreas protocol.

BACKGROUND: Pancreatic cancer is the fourth leading cause of cancer-related death in United States. We compared Computed Tomography (CT) with pancreas protocol and Endoscopic Ultrasound (EUS) in terms of mass detection, mass size, vascular involvement and lymph node involvement. METHODS: We retrospectively evaluated 93 patients. Concordance between CT and EUS, and accuracy of CT and EUS were assessed using a retrospective chart review and statistical analysis. RESULTS: CT and EUS agreed on mass detection in 88% of the cases and mass size in 67% of the cases. They agreed in 74% of cases about the presence or absence of vascular involvement and 82% in lymph node involvement. Cohen's kappa indicated that the concordance between two tests was moderately reliable. CONCLUSION: CT and EUS agree moderately well in identifying characteristics of pancreatic masses, but discrepancies between the two modalities are common, particularly with respect to involvement of specific blood vessels and lymph nodes. Clinicians should use caution in relying on a single modality to make decisions.

MCS9.7 enhancer activity is highly, but not completely, associated with expression of Irf6 and p63.

BACKGROUND: DNA variation in Interferon Regulatory Factor 6 (IRF6) contributes risk for orofacial clefting, including a common DNA variant rs642961. This DNA variant is located in a multi-species conserved sequence that is 9.7 kb upstream from the IRF6 transcriptional start site (MCS9.7). The MCS9.7 element was shown to possess enhancer activity that mimicked the expression of endogenous Irf6 at embryonic day 11.5 in transient transgenic embryos, and also contains a p63 binding site that transactivates IRF6 expression. To analyze whether the MCS9.7 enhancer is sufficient to drive IRF6 expression, we generated stable transgenic murine lines that carry a MCS9.7-lacZ transgene. We hypothesized that MCS9.7 was sufficient to recapitulate the endogenous expression of Irf6 at other time-points during embryonic development. RESULTS: We observed that MCS9.7 activity recapitulated endogenous Irf6 expression in most tissues, but not in the medial edge epithelium (MEE) at E14.5, when Irf6 expression was high during secondary palatal fusion. Also, while MCS9.7 activity and Irf6 expression were associated with p63 expression, we observed MCS9.7 activity and Irf6 expression in periderm, although p63 was absent. CONCLUSION: These data suggest that MCS9.7 enhancer activity is not sufficient to recapitulate IRF6 expression, and that p63 expression is not always necessary nor sufficient for transactivation of IRF6.