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.

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.

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.

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 treatment for small bowel obstruction: report of a case.

An unusual case of small bowel obstruction in a patient with "virgin abdomen" was successfully diagnosed and the localized pathology was elucidated by a computed tomography scan, and the case was successfully treated by laparoscopy.

Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study.

BACKGROUND: The feasibility, efficacy, and safety of the TriClip in the management of peptic ulcer hemorrhage in human beings are scarcely reported in the literature. OBJECTIVE: A pilot study was conducted to assess the feasibility, efficacy, and safety of the TriClip endoscopic clipping device in the control of peptic ulcer hemorrhage. DESIGN: Prospective evaluation. SETTING: Regional government hospital. PATIENTS: From July 2004 to January 2005, patients older than 16 years and with Forrest type I and IIa peptic ulcer hemorrhages were included in the study. INTERVENTIONS: TriClips were used for initial hemostasis. Salvage procedures, including adrenalin injection, heat probe application, argon plasma coagulation, or surgery will be carried out appropriately if TriClip failed to control bleeding alone. An endoscopy was repeated 24 hours later for the security of the TriClip and for any endoscopic evidence of recurrent bleeding. A follow-up endoscopy was performed 8 weeks later to assess ulcer healing. MAIN OUTCOME MEASUREMENTS: Procedure time, successful hemostatic rate, number of clips used, ulcer recurrent bleeding rate, complications, and ulcer healing rate were measured. LIMITATIONS: No comparative arm; pilot study only. RESULT: A total of 27 cases (11 women, 16 men) were included in the study, with a median age of 70 years (range 18-88 years). There were 19 cases of duodenal ulcer and 8 cases of gastric ulcer, with median size of 8 mm (range 2-20 mm). The rate of successful hemostasis in the first endoscopy by TriClips alone was 81.5% (22/27), with a median procedure time of 10 minutes (range 3-30 minutes). In the second endoscopy, the endoscopic recurrent bleeding rate was 14.8% (4/27) and the TriClips were found dislodged in 11 patients (40.7%). The permanent hemostasis rate was 67% (18/27). The overall failure rate was 33% (9/27). Three patients required blood transfusion before the first endoscopy. There was no morbidity or mortality observed in all cases. All ulcers healed after 8 weeks. CONCLUSIONS: The use of the TriClip is feasible in the initial control of peptic ulcer hemorrhage. However, we could not detect any obvious advantages in arresting bleeding vessels by using this new clipping device.