Voluminous paraumbilical hernia containing the pancreas - An unusual cause of acute pancreatitis: A case report.

INTRODUCTION: The paraumbilical hernia sac often contains the omentum, the small bowel, and less commonly the colon. The herniation of the pancreas through a paraumbilical hernia is extremely rare and has been reported only by two cases in the literature; moreover, acute pancreatitis secondary to this condition is a particularly unusual event. CASE REPORT: We present a very unusual case of a 67-year-old female patient with a voluminous paraumbilical hernia containing the pancreas, complicated by acute pancreatitis. Laboratory data revealed an elevation of the pancreatic enzymes. An intravenous contrast-enhanced computed tomography (CT) scan of the abdomen demonstrated a large hernia sac containing multiple viscera, including the pancreas. The patient underwent emergency laparotomy with a diagnosis of intestinal obstruction. CONCLUSION: The clinicians should consider this rare condition in the differential diagnosis of patients presenting with large paraumbilical hernias associated with classical symptoms of acute pancreatitis, particularly in the absence of typical risk factors for pancreatitis. An intravenous contrast-enhanced abdominal CT scan should be performed immediately in these patients. We recommend the patients and the surgeons to consider prompt surgical repair for paraumbilical hernias to avoid further complications and the higher incidence of morbidity and mortality associated with emergency surgeries.

Three-Dimensional Versus Two-Dimensional Laparoscopic Cholecystectomy: Is Surgeon Experience Relevant?

BACKGROUND: A prospective randomized comparison of three-dimensional (3D) versus two-dimensional (2D) imaging during elective laparoscopic cholecystectomy (LC), both performed separately by an advanced laparoscopic surgeon and by a surgeon experienced in open surgical procedures but a novice at laparoscopic procedures, was designed to address the issue of whether 3D systems offer real operative time advantages to this laparoscopic procedure. PATIENTS AND METHODS: Eighty patients were randomized the day of surgery by random computer-generated allocation list to receive either a 3D or 2D high-definition imaging system LC by two surgeons with differing experience. After the insertion of the access ports the surgical procedure was divided in two component tasks. Operative times of the two component tasks and the entire procedure were recorded. RESULTS: The execution times for the two component tasks and the entire procedure were not significantly different between the 2D and 3D groups for the experienced laparoscopic surgeon. However, the execution times for the two component tasks and the entire procedure were significantly faster during 3D compared with 2D for the novice surgeon. Both surgeons experienced better depth perception with the 3D system and subjectively reported less strain using 3D rather than 2D vision. CONCLUSIONS: 3D imaging seems not to influence the performance time of LC by an experienced laparoscopic surgeon. Less experienced laparoscopic surgeons could benefit from shorter performance time with 3D imaging due to no need to adapt to 2D vision. Further comparative studies are necessary to verify on great numbers of cases whether 3D can reduce intraoperative complications such as biliary lesions.

Three-Dimensional (3D) Versus Two-Dimensional (2D) Laparoscopic Bariatric Surgery: a Single-Surgeon Prospective Randomized Comparative Study.

BACKGROUND: To address the issue whether three-dimensional (3D) offers real operative time advantages to the laparoscopic surgical procedure, we have designed a single-surgeon prospective randomized comparison of 3D versus two-dimensional (2D) imaging during two different bariatric procedures. METHODS: Forty morbidly obese patients were randomized on the day of surgery by a random computer-generated allocation list to receive either a 3D high-definition (HD) display or 2D HD imaging system laparoscopic bariatric procedure by a single experienced surgeon. Forty operations were performed with either a 3D HD display or 2D HD imaging system. After the insertion of the access ports, both surgical procedures were divided in component tasks, and the execution times were compared. RESULTS: The execution times for the entire procedure and the single tasks were not significantly different between the 2D and 3D groups during sleeve gastrectomy. The execution times for the entire procedure and the single tasks, except for the first one, were significantly different between the 2D and 3D groups during mini-gastric bypass (p < 0.05). The surgeon experienced better depth perception with the 3D system and subjectively reported less strain using 3D vision system rather than the 2D system particularly during longer procedure. CONCLUSIONS: 3D imaging seems to decrease the performance time of more difficult bariatric procedures, which involve surgical tasks as suturing and intestinal measurement. Further comparative studies are necessary to address the issue if novice surgeons could benefit from reduced learning curve requested with 3D vision and to verify with greater numbers if 3D imaging can reduce complications.

Reversible bilio-pancreatic diversion with explorable excluded stomach-the Messina technique.

The authors propose a reversible bilio-pancreatic diversion with access to the bypassed stomach. In the Messina technique, bilio-pancreatic diversion is accomplished by transecting the stomach without gastric resection, as already described by Resa et al. In addition, a temporary gastrostomy is performed on the excluded stomach and allows direct postoperative exploration of the duodenum and the biliary tree. The Messina bilio-pancreatic diversion technique (MBPDT) seems to be safe and effective. The authors propose the MBPDT in a morbidly obese patient undergoing bariatric surgery when a malabsorptive operation is required, as it makes the original Scopinaro operation reversible, the bilio-pancreatic area explorable postoperatively, the operation shorter, and does not cause any significant increase in the postoperative complication rate. Larger numbers and longer follow-up, however, are needed to further confirm our data.

Single-incision versus three-port conventional laparoscopic right hemicolectomy: is there any real need to go single?

BACKGROUND: Preliminary results showed some benefits of single-incision laparoscopic surgery (SILS) over conventional laparoscopic colectomy, including better cosmesis, less postoperative pain, and faster recovery, but these results need further confirmation. In addition, the literature still lacks comparative studies between the two approaches to prove the above-mentioned advantages of SILS over conventional laparoscopy and, most importantly, its equivalent effectiveness in terms of initial oncological results. PATIENTS AND METHODS: Two consecutive series of 10 patients undergoing three-port conventional laparoscopic right hemicolectomy (3PCL-RH) and single-incision laparoscopic right hemicolectomy, respectively, were compared in their short-term surgical and oncological outcomes. RESULTS: Analysis of perioperative and postoperative outcomes revealed no significant differences between the two groups. In the SILS group an anastomotic leakage occurred, which was conservatively treated by continuous drainage, total parental nutrition, and antibiotic therapy. The analysis of oncological outcomes showed no differences in terms of length of distal tumor-free margin and harvest of lymph nodes. CONCLUSIONS: Despite its feasibility for right hemicolectomy and its equivalent short-term surgical and oncological outcome compared with conventional laparoscopy, SILS demonstrated no significant advantages in terms of surgical incision length and postoperative course compared with 3PCL-RH. We acknowledge that the small sample size and the nonrandomized design are a limit of the study. Thus, prospective randomized controlled trials are recommended to prove the superiority of single-incision laparoscopic right hemicolectomy.

SILS and NOTES cholecystectomy: a tailored approach.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been proposed as different solutions to further minimize the invasiveness of laparoscopy. In this article, we present our experience with NOTES and SILS over the last few years, trying to focus on identifying which technique should be offered to which patients at the beginning of 2010. PATIENTS AND METHODS: Between January 2009 and January 2010, 100 patients were diagnosed with symptomatic cholelithiasis at our department. Considering our positive previous experiences with NOTES and SILS, we offered the hybrid NOTES approach to women over 40 years with no previous pelvic surgery or history of inflammatory pelvic disease and SILS to male patients and women excluded from the hybrid NOTES approach, with previous surgery in the upper right quadrant and gallbladder empyema being the main contraindications. RESULTS: Twenty-six patients accepted the SILS or NOTES approach instead of standard laparoscopic cholecystectomy (LC). Seventy-four patients underwent standard LC via four trocars. In the hybrid NOTES transvaginal cholecystectomy, there were no problems or complications related to the culdotomy, trocar, or stay suture placement. There were no conversions, and all the procedures were performed as planned without complications. In the SILS cholecystectomy, there were no problems or complications related to the trocar or stay sutures placement. All the procedure were completed without complications. CONCLUSIONS: NOTES and SILS are promising techniques that need new, dedicated instrumentations to reduce technical limitations. Randomized studies comparing SILS/NOTES and traditional laparoscopy are necessary to evaluate safety, efficacy, and potential benefits.

Hybrid transvaginal cholecystectomy: a novel approach.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) allows cholecystectomy to be performed by means of a flexible scope introduced through the stomach, rectus, bladder, or vagina. However, available endoscopes have several limitations if used in the peritoneal cavity. The hybrid technique reported overcomes these limitations by using conventional 5-mm laparoscopic instruments through the umbilical scar and transabdominal sutures for retraction. After creating the pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the umbilicus followed by a 5-mm, 30 degrees scope. A culdotomy then is performed under direct and laparoscopic views. The flexible endoscope is inserted into the pelvis through the vagina and advanced to expose the gallbladder. Three or more transabdominal sutures are placed through the gallbladder wall for retraction. Cholecystectomy then is performed using conventional 5-mm laparoscopic instruments through the 5-mm umbilical port. Finally, stay sutures are removed and the specimen is retrieved through the vagina. Six patients successfully have undergone this new procedure. In our opinion this hybrid approach increases safety, overcomes the limitation of the current instrumentation, and maintains most of the advantages of Natural Orifice Transluminal Endoscopic Surgery.