A man with recurrent lower abdominal pain: Spigelian hernia.

Recurrent abdominal pain due to spigelian hernia (SH) is rare and notoriously difficult to diagnose. This is particularly true when patient present with pain only without visible or palpable mass. Ultrasonic scanning and computed tomography is valuable in diagnosing this rare condition. However, for a small hernia with its content reduced spontaneously during examination, even computed tomography will miss the diagnosis. In the era of laparoscopic surgery, the role of laparoscopy in the management of recurrent abdominal pain of unknown origin has become more and more important. It is especially true in the management of SH as it is both diagnostic and therapeutic. We report a case of SH presented as recurrent lower abdominal pain of unknown origin and its successful diagnosis and treatment by laparoscopic approach.

Unusual cause of acute abdomen --- ruptured retroperitoneal paraganglioma.

Ruptured retroperitoneal paraganglioma is a rare cause of acute abdomen. Its clinical presentation and laparoscopic features have seldom been reported in the literature. Herein, we report a case of ruptured retroperitoneal paraganglioma that presented as acute abdomen, and its subsequent management.

Risk of deep vein thrombosis following laparoscopic rectosigmoid cancer resection in chinese patients.

OBJECTIVE: The aim of this study was to evaluate the incidence of postoperative deep vein thrombosis (DVT) in Chinese patients who underwent laparoscopic resection of rectal or sigmoid cancer in the absence of thromboprophylaxis. METHODS: Patients with adenocarcinoma of the sigmoid colon or rectum scheduled for laparoscopic resection were recruited. Neither chemoprophylaxis nor mechanical methods against DVT were employed. They were scheduled to have routine duplex ultrasound of both lower limbs perioperatively. RESULTS: In a 12-month period, 50 patients were recruited. Postoperative DVT occurred in 19 (38%) patients. None needed anticoagulation. Complete resolution of the thrombus was noted in 10 (53%) patients 12 weeks after operation, and in six patients 36 weeks after operation. Female sex was identified as being associated with a higher incidence of DVT. Age, smoking, preoperative neoadjuvant chemoirradiation, preoperative metastasis, duration of operation, conversion and postoperative complications did not appear to be risk factors for DVT. CONCLUSION: The incidence of asymptomatic calf vein DVT is relatively high after laparoscopic resection for rectosigmoid cancers in the Chinese population. However, complete resolution occurred without the use of anticoagulant therapy in the majority of cases. It is thus difficult to advocate the routine use of anticoagulant prophylaxis.

Laparoscopic versus open appendectomy for complicated appendicitis.

BACKGROUND: Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis; various reports demonstrated its merits in assisting diagnosis, reducing postoperative pain, analgesic requirement, and incidence of wound infection. The role of laparoscopy in management of complicated appendicitis, ie, gangrenous, perforated appendicitis and appendiceal abscess, remains undefined. Currently, the choice of operative approach is mostly at the surgeons' discretion. A retrospective study was conducted in our institution to review the feasibility, safety, and efficacy of laparoscopic appendectomy for patients with complicated appendicitis. STUDY DESIGN: From January 1999 to January 2004, records of patients older than 14 years of age with diagnosis of appendicitis were retrieved from computer database for analysis. All patients underwent diagnostic laparoscopy to confirm diagnosis of complicated appendicitis, and patients subsequently underwent either laparoscopic or open appendectomies. Patients' demographics data and perioperative outcomes from the two groups were compared. RESULTS: During the study period, 1,133 patients with acute appendicitis underwent operations in our institution. Two hundred forty-four patients (21.5%) with complicated appendicitis were identified by laparoscopy, of which 175 underwent laparoscopic appendectomy (LA) and 69 had open appendectomy (OA). Both groups of patients were comparable in demographics. Mean operative time was 55 minutes for LA group and 70 minutes for the OA group (p<0.001). Mean hospital stay was 5 days and 6 days for LA and OA group respectively (p<0.001). There was one conversion patient (0.6%) in the LA group who suffered from wound infection, and there were seven (10%) wound infections in the OA group (p=0.001). There were 10 cases (5.7%) of intraabdominal collection in the LA group and 3 (4.3%) in the OA group (p=0.473). There was no mortality in the current series. CONCLUSIONS: Laparoscopic appendectomy for complicated appendicitis is feasible and safe. It is associated with a significantly shorter operative time, lower incidence of wound infection, and reduced length of hospital stay when compared with patients who had open appendectomy.

Laparoscopic management of acutely incarcerated femoral hernia.

Incarcerated femoral hernia is a common surgical emergency condition. Diagnosis is always obvious and straightforward by clinical examination, and open surgical repair is the mainstay of treatment. In the era of minimally invasive surgery, laparoscopic repair of femoral hernia has been shown to be feasible and safe. However, laparoscopic repair of acutely incarcerated femoral hernia has gained little discussion in the past. In this paper, we report the results of 8 consecutive cases of strangulated femoral hernia that was successfully managed by the laparoscopic approach.

Migrating gallstone: from Bouveret's syndrome to distal small bowel obstruction.

Gallstone ileus is an uncommon cause of small bowel obstruction. When the gallstone lodges inside the duodenum and causes gastric outlet obstruction, it is termed Bouveret's syndrome. However, it is rather unusual to seen the evolution of a migrating gallstone (from duodenum to distal small bowel) in a patient during the same hospital admission. We report a case of gallstone ileus from the initial presentation of gastric outlet obstruction to the development of distal small bowel obstruction within the same hospital admission, and its total laparoscopic treatment.

Strangulated appendix epiploica in paraumbilical hernia: preoperative diagnosis and laparoscopic treatment.

Appendix epiploica can occasionally cause acute abdominal pain. The usual presentations are torsion or primary epiploic appendicitis. Strangulation inside a paraumbilical hernia with acute abdominal pain is seldom reported in the literature. The authors report a case of preoperative diagnosis and laparoscopic treatment of strangulated appendix epiploica in paraumbilical hernia that presented as acute abdominal pain.

Laparoscopic cholecystectomy for acute cholecystitis: the evolving trend in an institution.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis (AC). We review the evolving role of LC for AC in our institution. METHODS: A retrospective study was conducted of patients who received LC for AC between January 1994 and June 2001. Patients' demographics, clinical findings and perioperative outcomes were evaluated. RESULTS: There were 140 men and 141 women with a mean age of 56.9 years (range, 23-89 years). Two hundred and eighteen of these patients underwent successful LC. There were 63 conversions (22.4%) for uncertain anatomy and difficult dissection (41), gangrenous or perforated gallbladder (16) and bleeding (6). The conversion rates as stratified to surgeon's seniority were 25.1%, 22.8% and 9.7% for registrar, senior registrar and consultant, respectively. The mean operative time was 84.3 minutes (range, 30-255 minutes) and the mean postoperative stay was 5.8 days (range, 1-35 days). The overall complication rate was 11.6%, including two bile duct injuries and two perioperative deaths. CONCLUSION: LC for AC is safe and effective and associated with a low incidence of complications when routinely applied by surgical residents. The conversion rate is related to operators' surgical experience.

Acute symptomatic abdominal aortic aneurysm secondary to endovascular stent graft associated type II endoleak.

Endovascular abdominal aneurysm repair (EVAR) is popular because of its low invasiveness and feasibility for high-risk patients. Endoleak is common after EVAR and is characterized by blood flow within the aneurysm sac but outside the stent graft. Type II or collateral endoleak commonly results from retrograde filling of the aneurysm from collateral visceral vessels, lumbar, inferior mesenteric, accessory renal or sacral arteries. Collateral leaks are generally thought to be benign and over half of the early leaks will seal spontaneously. Sporadically, collateral endoleak could lead to aneurysm sac pressurization and place the patient at ongoing risk of rupture. Herein, we report an uncommon case of early post-stent graft placement symptomatic abdominal aortic aneurysm associated with type II endoleak.

Abdominal tuberculosis mimicking metastasis in a patient with carcinoma of the oesophagus.

Oesophageal carcinoma typically manifests as ulcerative growth. Cases of oesophageal tuberculosis mimicking carcinoma of the oesophagus have been reported and create considerable diagnostic difficulty. Abdominal tuberculosis, however, is an uncommon extrapulmonary manifestation of tuberculosis. Here, we report a case of abdominal tuberculosis in a patient with squamous carcinoma of the oesophagus.

Laparoscopic approach compared with conventional open approach for bezoar-induced small-bowel obstruction.

BACKGROUND: Bezoar-induced small-bowel obstruction (SBO) is an uncommon surgical emergency. Accurate preoperative diagnosis is notoriously difficult, and conventional management often necessitates laparotomy. Recent articles demonstrate the feasibility of laparoscopy in the management of SBO. This study compares the outcomes of a series of cases managed laparoscopically with the outcomes of matched open cases. HYPOTHESIS: Laparoscopic management of bezoar-induced SBO is safe and effective when compared with traditional laparotomy treatment. PATIENTS AND METHODS: A retrospective study was conducted from November 1, 1998, to November 30, 2003, to compare laparoscopic vs open treatment for bezoar-induced SBO. Patients' demographics, operative details, and surgical outcomes were evaluated. RESULTS: During the study period, 24 patients (16 men and 8 women) with a mean age of 68.2 years underwent operative treatments for bezoar-induced SBO. Ten patients received laparoscopic treatments and the other 14 received laparotomy treatments. The patients were comparable in age, sex, and physiological status. There were 3 conversions in the laparoscopy group owing to technical difficulties. The laparoscopic approach was associated with statistically significant shorter operative time (P = .048), fewer postoperative complications (P = .04), and reduced hospital stay (P = .009). CONCLUSIONS: When expertise is available, laparoscopy is safe and effective in the management of bezoar-induced SBO and is associated with superior postoperative outcomes when compared with the conventional open approach.

Acute abdomen: an unusual case of ruptured tuberculous mesenteric abscess.

BACKGROUND: Abdominal tuberculosis is an uncommon extra-pulmonary manifestation of tuberculosis. METHODS: Case report and literature review. RESULTS: Herein, we report an unusual case of ruptured tuberculous mesenteric cold abscess, which was managed by laparotomy for diagnosis and drainage, and post-operative chemotherapy. CONCLUSIONS: Peritoneal tuberculosis may present to surgeons as ascites, an abdominal mass, or peritonitis. Preoperative diagnosis of abdominal tuberculosis is notoriously difficult. Acute peritonitis provoked by rupture of tuberculosis mesenteric cold abscess is exceedingly rare. Surgical intervention is warranted for diagnosis and drainage.

Laparoscopy-assisted surgical management of obscure gastrointestinal bleeding secondary to Meckel's diverticulum in a pediatric patient: case report and review of literature.

Despite advances in endoscopy and imaging, acute gastrointestinal (GI) bleeding of obscure origin in children presents a challenge to pediatric gastroenterologist. Bleeding Meckel's diverticulum (MD) commonly presents with acute episode of lower GI bleeding. A conventional diagnostic algorithm includes endoscopy, technetium 99m pertechnetate scintigraphy, angiography, and exploratory laparotomy. The advent of minimal access surgery prompts the use of laparoscopy for children with obscure GI bleeding. Laparoscopy assists in the diagnosis and can offer definitive treatment of patients with MD. Herein, we report a case of pediatric GI bleeding of obscure origin associated with MD that was successfully diagnosed and managed via laparoscopy. This article updates the current management for pediatric patients with obscure GI bleeding and the role of laparoscopy in the management of MD.

Diaphragmatic hernia: an uncommon cause of dyspepsia.

Adult onset diaphragmatic hernia is a rare condition with variable clinical manifestations. The majority of adult-onset diaphragmatic hernia is associated with trauma. Blunt thoracic and abdominal trauma associated with a 5% to 7% incidence of diaphragmatic injury, and in 3% to 15% for those with penetrating injury. These injuries may be left unrecognized when they occur but often are uncovered months later during work up for related symptoms. Prompt diagnosis and surgical repair is recommended by most authorities. Traditionally, diaphragmatic hernia is repaired by laparotomy or thoracotomy, or both. Herein, we report a case of adult onset diaphragmatic hernia presented with dyspepsia that was successfully repaired via laparoscopy. Operative approach and technique of diaphragmatic defect closure is elucidated.

Therapeutic minilaparoscopy for perforated peptic ulcer.

Laparoscopic repair for perforated peptic ulcer has been demonstrated to be safe and effective. We report our initial experience of applying therapeutic minilaparoscopy for peptic ulcer perforation. Five patients with perforated peptic ulcers managed by a team of surgeons using minilaparoscopy are reported. There were no conversions, perioperative morbidity, or mortality. Patients experienced minimal wound pain and required minimal parental analgesia. The access wound scars were hardly discernable at 3-month followup. Therapeutic minilaparoscopy is technically feasible for patients with perforated peptic ulcer and is associated with satisfactory clinical and cosmetic outcome.

Laparoscopic repair of iatrogenic endoscopic perforated peptic ulcer.

Iatrogenic perforation is an uncommon but inevitable complication of endoscopy. Laparotomy has been the standard treatment for pyloroduodenal perforations caused by endoscopy. Laparoscopic repair is a well-documented treatment modality for spontaneously perforated peptic ulcer. We report our successful laparoscopic suture repair of perforations sustained during upper gastrointestinal endoscopy in two high-risk elderly patients.

Vagotomy and gastrojejunostomy for benign gastric outlet obstruction.

OBJECTIVE: Peptic-ulcer-induced gastric outlet obstruction is an indication for operative intervention. The advent of minimal access surgery allows the conventional open procedure to be performed via laparoscopy. PATIENTS AND METHODS: From 1996 to 2000, 15 consecutive patients, aged 29 to 75 years, underwent laparoscopic truncal vagotomy and gastrojejunostomy for gastric outlet obstruction. Perioperative data and longterm followup results were analyzed. RESULTS: There were no conversions or perioperative mortality. The mean operative time was 114 minutes. Patients required on average 1 dose of intramuscular pethidine for analgesia. Eleven patients were discharge by postoperative day 10; the remaining 4 patients had delayed gastric emptying which settled with conservative treatment. With an average followup period of 80 months, patients were classified as Visick I (n = 7), II (n = 5), III (n = 1), and IV (n = 2). CONCLUSION: Laparoscopic truncal vagotomy and gastrojejunostomy is technically feasible for patients with benign gastric outlet obstruction and is associated with satisfactory perioperative and longterm outcome.

Laparoscopic management of omental torsion secondary to an occult inguinal hernia.

Torsion of the greater omentum is an uncommon surgical emergency. Most of the reported cases have been primary omental torsion with infarction, in which the underlying cause is largely unknown. Right-sided abdominal symptoms are the predominant complaint. Left-sided omental torsion is rather infrequent, and the preoperative diagnosis is extremely difficult. We report a case of omental torsion secondary to an occult left indirect inguinal hernia that was successfully diagnosed and managed laparoscopically.

Hand-assisted D2 subtotal gastrectomy for carcinoma of stomach.

We report a case of hand-assisted D2 subtotal gastrectomy with Roux-en-Y reconstruction for advanced gastric cancer. This case shows the advantages of hand-assisted laparoscopic surgery for gastric cancer. Extended lymph node dissection and intracorporeal anastomosis are feasible and easier with the presence of the internal hand. Our method is an alternative to total laparoscopic radical gastrectomy.