Acute abdomen due to strangulated intravesical hernia with incidental finding of kidney tumor: A case report and literature review.

Internal supravesical hernia is a rare type of internal abdominal hernia with overall incidence <4% of all internal abdominal hernias. The clinical diagnosis is a major preoperative diagnostic challenge for both the surgeon and the radiologist. It is a rare cause of small bowel obstruction, but in case of strangulation it can be fatal and it necessitates urgent surgical intervention. In this case study, we report a case of intravesical type of supravesical hernia in a 63-year-old man with acute intestinal obstruction and an accidental finding of a kid-ney tumor. In the article, we discuss the clinical picture, diagnosis, risk factors, treatment strategy and complications of this rare entity.

A prospective cohort study for prediction of difficult laparoscopic cholecystectomy.

INTRODUCTION: Difficult laparoscopic cholecystectomy (DLC) is a stressful condition for surgeon which is followed by greater risk for various injuries (biliary, vascular etc.) Preoperative factors that are related to DLC are landmarks for surgeon to assess the possibilities for overcoming difficulties and making early decision about conversion to an open surgery. In prospective cohort study we evaluated and defined the importance and impact of preoperative parameters on difficulties encountered during surgery, defined DLC, predictors of DLC and index of DLC. MATERIALS AND METHODS: All patients in the study were operated by the same surgeon. We defined the total duration of the operation as the time from insertion of Veress needle to the extraction of gallbladder (GB) and DLC as a laparoscopic cholecystectomy (LC) that lasted longer than the average duration of LC and the value of one standard deviation. RESULTS: Multivariate logistic regression analysis identified five predictors significantly related to DLC: GB wall thickness > 4 mm, GB fibrosis, leukocytosis ˃10 × 109 g/L, ˃ 5 pain attacks that lasted longer than 4 h and diabetes mellitus. The sensitivity of the generated index of DLC in our series is 81.8% and specificity 97.2%. CONCLUSION: Preoperative prediction of DLC is important for the surgeon, for his operating strategy, better organization of work in operating room, reduction of treatment expenses, as well as for the patient, for his timely information, giving a consent for an operation and a better psychological preparation for possible open cholecystectomy (OC).

Feasibility of applying data mining techniques for predicting technical difficulties during laparoscopic cholecystectomy based on routine patient work-up in a small community hospital.

BACKGROUND/AIMS: Predicting technical difficulties in laparoscopic cholecystectomy (LC) in a small regional hospital increases efficacy, cost-benefit and safety of the procedure. The aim of the study was to assess whether it is possible to accurately predict a difficult LC (DLC) in a small regional hospital based only on the routine available clinical work-up parameters (patient history, ultrasound examination and blood chemistry) and their combinations. METHODOLOGY: A prospective, cohort, of 369 consecutive patients operated by the same surgeon was analyzed. Conversion rate was 10 (2.7%). DLC was registered in 55 (14.90%). Various data mining techniques were applied and assessed. RESULTS: Seven significant predictors of DLC were identified: i) shrunken (fibrotic) gallbladder (GB); ii) ultrasound (US) GB wall thickness >4 mm; iii) >5 attacks of pain lasting >5 hours; iv) WBC >10x109 g/L; v) pericholecystic fluid; vi) urine amylase >380 IU/L, and vii) BMI >30kg/m2. Bayesian network was selected as the best classifier with accuracy of 94.57, specificity 0.98, sensitivity 0.77, AUC 0.96 and F-measure 0.81. CONCLUSION: It is possible to predict a DLC with high accuracy using data mining techniques, based on routine preoperative clinical parameters and their combinations. Use of sophisticated diagnostic equipment is not necessary.

[A prospective evaluation of laparoscopic cholecystectomy in the treatment of chronic cholelithiasis--a five-year experience].

INTRODUCTION: Laparoscopic cholecystectomy is a method of choice in the treatment of symptomatic cholecystolithiasis because of less postoperative pain, shorter hospitalization and lower cost of treatment. The study was aimed at analysing the outcome of laparoscopic cholecystectomy in patients surgically treated for chronic calculous cholecystitis (symptomatic cholelithiasis). MATERIAL AND METHODS: The research was done in the period from December 2003 to December 2008. In the prospective study of 386 patients, we analyzed operative and postoperative complications, the reasons for conversion to open cholecystectomy, duration of hospitalization and mortality. RESULTS: The average duration of laparoscopic cholecystectomy was 31.9 +/- 14.5 min: dissection of adhesions 3.2 +/- 0.7 min., elements of Calot's triangle 9.8 +/- 3.2 min., gallbladder releasing from its bed 12.8 +/- 2.8 min., the abdominal cavity lavage and removal of gallbladder from the abdomen 6.8 +/- 0.9 min. Some operative difficulties emerged in 22 (5.7%) patients--4 (1%) during releasing of gallbladder adhesions from the surrounding structures, 9 (2.3%) during dissection of elements of the Calot's triangle, 6 (1.5%) during gallbladder releasing from its bed, 3 (0.7%) during gallbladder removal from the abdomen. Some post-operative complications, single or associated, occurred in 36 (9.3%) patients: perforation of gallbladder 21 (5.4%), bleeding from gallbladder bed 18 (4.6%)/ injury of extra hepatic bile ducts 1 (0.20%), 9 (2.3%) spillage of stones; 3 (0.7%) conversions were made. The average duration of preoperative and postoperative hospitalization was 1.1 +/- 0.3 and 1.4 +/- 0.5 days, respectively. The pathohistological examination revealed 2 (0.5%) adenocarcinoma of gallbladder. There were no lethal outcomes. CONCLUSION: Laparoscopic cholecystectomy is a safe procedure and rational choice in the treatment of biliary dyskinesia and symptomatic biliary calculosis with an acceptable rate of conversion.

[Laparoscopic cholecystectomy of acute cholecystitis].

INTRODUCTION: Laparoscopic cholecystectomy is a method of choice for surgical treatment of diseases of gallbladder. Although most surgeons today use laparoscopic cholecystectomy in treatment of severe acute cholecystitis, most surgeons still consider acute cholecystitis a relevant contraindication for laparoscopic cholecystectomy because of "confused" anatomy and "severe" pathology. Aim of the study was to analyze laparoscopic cholecystectomy outcomes in treatment of acute cholecystitis. MATERIAL AND METHODS: A prospective analysis included 78 patients operated for acute calculose cholecystitis from Jan 2007 to Dec 2008. We analyzed clinical characteristics of the course of disease, associated diseases, duration of operation, operative and postoperative complications, reasons for conversion into open cholecystectomy. RESULTS: The study indicated a low percentage of operative and postoperative complications, short stay in hospital, quick recovery and saving in treatment. The length of preoperative and postoperative hospitalization was 1.4 +/- 0.5 days and 2.5 +/- 1.6 days, respectively. 25 (32%) patients were operated within 72 hours from the onset of symptoms,some operative difficulties were present in 56 (71%) patients, light identification of artery and ductus cysticus in 30 (38.50%) patients, intraoperative lesion of ductus choledohus in 1 (1.3%); in 6 (7.7%) patients conversion into open cholecystectomy was done, the average duration of laparascopic cholecystectomy was 58.1 +/- 26.2 min. There were no lethal outcomes. CONCLUSION: Laparoscopic cholecystectomy is an efficient and reliable operative procedure in treatment of acute cholecystitis. It is much easier to select patients for laparoscopic cholecystectomy when preoperative risk factors predicting difficulties during the operation are known. An early conversion into open cholecystectomy is a rational choice of any surgeon when anatomy is not clear and in cases of advanced inflammatory process in order to decrease operative and postoperative morbidity.