Laparoscopic Surgery for an Intussusception Caused by a Lipoma in the Ascending Colon

A colonic intussusception caused by an intraluminal lipoma is a rare disease in adults, in whom it usually has a definite organic cause. In fact, it is either caused by a benign or a malignant condition, both of which occur at similar rates. However, little literature is available on laparoscopic procedures for use in cases of adult colonic intussusceptions. Recently, a 52-year-old woman was admitted to our hospital with abdominal pain of one-month duration. Abdominal computed tomography showed an intussusception with a fat-containing mass in the right hepatic area. Colonoscopy showed a colon lumen occupied by the mass. A right hemicolectomy was performed laparoscopically, and the cause of the intussusception was found to be a lipoma. Before obtaining histological confirmation, we carefully perform a laparoscopic procedure, which required consideration of the relations between the involved colonic segment and other conditions such as the location of main vessels, the anatomical exposure with respect to colonic mobilization and the location of specimen retrieval.

Comparison of Clinical Characteristics between Single Incision Laparoscopic Appendectomy

PURPOSE: Conventional laparoscopic appendectomy (LA) is a widely used treatment for appendicitis. Nowadays, single incision laparoscopic appendectomy (SILA) is increasingly used as an alternative treatment for appendicitis. The purpose of this study is to evaluate the clinical significance and differences between LA and SILA. METHODS: A total of 519 patients undergoing LA or SILA between January 2011 and December 2012 were identified in a retrospectively collected database. Patients' characteristics and peri-operative variables were analyzed. RESULTS: LA was performed in 485 patients and SILA was performed in 34 patients. Mean operation time for the LA group was 62.7 minutes (range 23.3~68.1) and that for the SILA group was 62.7 minutes (range 50.9~74.5). This difference of operation time was statistically significant. In the learning curve of SILA, operation time was gradually decreased. No significant differences in hospital stay and peri-operative complications were observed between groups. CONCLUSION: Although operation time for SILA was longer than that for LA, SILA was safe. Therefore, a prospective study should be conducted in order to confirm the possibility of application to most appendicitis patients.

Perineal accessory scrotum with a lipomatous hamartoma in an adult male / 대한외과학회지

Accessory scrotum is a rare congenital anomaly that is often associated with perineal tumor or other developmental abnormalities. Because most cases are diagnosed and treated in early childhood, little is known about the natural biologic course of this entity and associated lesions through time. We present a case of accessory scrotum associated with lipomatous hamartoma in a 46-year-old man who was born with a perineal mass. We evaluate the clinicopathologic features and discuss the pathogenesis with a review of the literature.

Advantage of Laparoscopic Appendectomy for Perforated Appendicitis / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy (LA) is currently more popular than an open appendectomy (OA), because of its advantages, such as a decrease in postoperative pain, short hospitalization and quick recovery. On the other hand, the efficacy and safety of a laparoscopic appendectomy for complicated appendicitis is controversial. Therefore, this study compared the efficacy and safety of LA and OA. METHODS: This study reviewed retrospectively 262 patients with perforated appendicitis who underwent ether open or laparoscoic appendectomy between January 2001 and December 2010. The medical record and video were used to collect data. The operative time, length of hospital stay, time to diet, time to remove drain and complications were assessed. RESULTS: There were 207 and 55 patients in the OA and LA group, respectively. The operation times were significantly longer in the LA group than the OA group (OA group 68.25+/-33.08 vs. LA group 90.80+/-47.64 min) (p<0.05). The length of hospital stay was longer in the OA group than the LA group (OA group 10.96+/-5.24 vs. LA group 8.86+/-5.18 days) (p<0.05). The time to diet and time to remove the drain was longer in the OA group than the LA group (p<0.05). The postoperative complication rate was similar in the two groups. CONCLUSION: The operative time was longer in the LA group but the length of hospital stay, time to diet, and time to remove drain was longer in the OA group. Such merits show that laparoscopic appendectomy is a good surgical option for perforated appendicitis.

50 Cases of Laparoscopic Appendectomy by One Surgical Resident: The Learning Curve and Safety / 대한내시경복강경외과학회지

PURPOSE: The frequency of performing laparoscopic appendectomy (LA) has increased compared to that of open appendectomy because of its advantages such as decreased postoperative pain, shorter hospitalization and quicker recovery. The advantages of minimally invasive surgery are well known to the general public, so we recognized the importance of a laparoscopic training course. We analyzed the results of LA performed by one resident and we determined the learning curve and the safety. METHODS: We retrospectively studied 50 consecutive patients with a preoperative diagnosis of acute appendectomy and who underwent LA by one surgical resident. We used the medical and video records and compared the patients' age, gender, BMI, the location of the appendix tip, the pathologic findings, the state of drainage insertion, intraoperative bleeding, conversion to open surgery, the operation time and the complicating factor affecting the operating time. RESULTS: The mean operation time was 79.9 minutes and the operation time was effectively shortened when the surgeon had many experiences, the patients had a low BMI and there was no perforation, periappendiceal abscess or insertion of drains. After 25 cases of surgery experience (LA), the surgeon had enough expertise for the operations. Two cases of wound infection around the umbilical area and 1 case of intraperitoneal fluid collection occurred after the surgery. Yet this was all soon cured by wound dressing and the use of antibiotics. CONCLUSION: Fifty cases of LA were safely performed by one surgical resident. Thus, LA is a suitable procedure for surgical residents and it helpful for learning the basic technique of other advanced laparoscopic surgeries.

The Level of Serum CEA Associated with Recurrence after Potentially Curative Surgery for Colorectal Cancer

PURPOSE: Carcinoembryonic antigen (CEA) is the most widely used tumor marker for detecting colorectal cancer. This study was designed to evaluate the level of serum CEA that is associated with recurrence after potentially curative surgery for colorectal cancer. METHODS: We retrospectively investigated the pre- and post-operative levels of serum CEA in 246 patients with colorectal cancer and they had undergone potentially curative surgery from 1996 through 2005. RESULTS: The pre-operative CEA level was significantly associated with the number of metastatic lymph nodes, the tumor size and the recurrence rate. The feature that was associated with recurrent disease on multivariate analysis was the pre-operative level of serum CEA. CONCLUSION: In order to detect the recurrence of colorectal cancer, we should closely follow up with frequent checks of the CEA level after surgery for those patients who had a high preoperative CEA level.

Significance of Serum Ferritin in Multiple Trauma Patients with Acute Respiratory Distress Syndrome

PURPOSE: Clinically, acute respiratory distress syndrome (ARDS) occurs within 72 hours after acute exposure of risk factors. Because of its high fatality rate once ARDS progresses, early detection and management are essential to reduce the mortality rate. Accordingly, studies on early changes of ARDS were started, and serum ferritin, as well the as injury severity score (ISS), which has been addressed in previous studies, thought to be an early predictive indicator for ARDS METHODS: From March 2003 to March 2005, we investigated 50 trauma patients who were admitted to the intensive care unit in Dongguk University Medical Center, Gyeongju. The patients were characterized according to age, sex, ISS, onset of ARDS, time onset of ARDS, serum ferritin level (posttraumatic 1st & 2nd day), amount of transfused blood, and death. Abdominal computed topography was performed as an early diagnostic tool to evaluate the onset of ARDS according to its diagnostic criteria. The serum ferritin was measured by using a VIDAS(R) Ferritin (bioMeriux, Marcy-1' Etoile, France) kit with an enzyme-linked fluorescent assay method. For statistical analysis, Windows SPSS 13.0 and MedCalc were used to confirm the probability of obtaining a predictive measure from the receiver operating characteristics (ROC) curve. RESULTS: The ISS varied from 14 to 66 (mean: 33.8) whereas the onset of ARDS could be predicted with the score above 30 (sensitivity: 90.0%, specificity: 60.0%, p<0.05). On the posttraumatic 1st day, the serum ferritin levels were measured to be from 31 mg/dL to 1,200 mg/dL (mean: 456 mg/dL), and the onset of ARDS could be predicted when the value was over 340 mg/dL (sensitivity: 80.0%, specificity: 65.0%, p<0.05). On the posttraumatic 2nd day , the serum ferritin levels were measured to be from 73 mg/dL to 1,200 mg/dL (mean: 404 mg/dL), and the onset of ARDS could be predicted when the value was over 627 mg/dL (sensitivity: 60.0%, specificity: 92.5%, p<0.05). The serum ferritin levels and the ISS were significantly higher on the posttraumatic 1st and 2nd day in the ARDS group, suggesting that they are suitable indices predicting the onset of ARDS, however relationship between the serum ferritin levels and the ISS was not statistically significant. CONCLUSION: In this study, we discovered increasing serum ferritin levels in multiple- trauma patients on the posttraumatic 1st & 2nd day and concluded that both the serum ferritin level and the ISS were good predictors of ARDS. Although they do not show statistically significant relationship to each other, they can be used as independent predictive measures for ARDS. Since ARDS causes high mortality, further studies, including the types of surgery and the methods of anesthesia on a large number of patients are essential to predict the chance of ARDS earlier and to reduce the incidence of death.

Clinical Manifestations and Microbiological Features Correlating with Central Venous Catheter Related Infection

PURPOSE: Central venous catheterization is widely used to supply substantial amounts of fluids, total parenteral nutrition and hemodialysis in renal failure patients, as well as for measuring the central venous pressure. The most common complications encountered during central venous catheterization include catheter-related infections and subsequent sepsis. Therefore, when fever exists in patients with a central venous catheter, an immediate blood culture should be performed, and if the fever persists, an infection must be suspected and the catheter immediately removed; a culture of the catheter tip should also be performed. To date, no definite clinical details relating to this matter have been reported. METHODS: Between December 2002 and March 2005, a retrospective study was undertaken using the medical records of 85 patients. In those patients where a fever lasted for more than 8 hours, or when catheterization was no longer needed, the catheter tip cultures were sent to the microbiology laboratory. Blood cultures were also performed on 49 patients with a fever. The Chi-square method using the PC SPSS program, with P value less than 0.05 as statically significant. RESULTS: Of the 85 patients where the catheters were removed, significant microorganisms were detected 20 of the 49 with a fever. Only 5 of the remaining 36 patients had their catheters spontaneously removed. Moreover, 14 of the 20 patients with significant microorganisms were found to have kept their catheter in place for more than 14 days. Of the 49 patients with a fever, in who blood cultures were undertaken, 13 showed specific microorganisms, with 6 of these showing the same results for both their blood and catheter tip cultures, which enabled the definite diagnosis of the catheter-related infection and underlying sepsis. Various microorganisms were detected from the catheter tip cultures, including Staphylococcus species the CNS, with S. aureus being the most common, at 61.6%. CONCLUSION: A central venous catheter should be removed immediately when an infection is suspected, but early broad-spectrum antibiotics therapy should be commenced due to the time required to obtain the culture results. Moreover, even if a fever does not exist in patients with a catheter inserted for more than 14 days, infection and sepsis from the catheter should be of concern, with a more cautious approach being mandatory.

Acute Appendicitis in Children under Age of 5 Years

PURPOSE: Acute appendicitis is one of the most common causes of abdominal emergency. Children, under age of 5 years, are unable to give an accurate history, but other nonspecific abdominal pain is more common at this age. Because diagnosis is often delayed and progression of appendicitis is faster, incidence and perforation rate is higher than those of adults. Abdominal US and CT are helpful in diagnosis of acute appendicitis. METHODS: Between July, 1997 and April, 2004, 39 patients below 5-year-old were participated, but 2 (Negative) patients were excluded. This study was done retrospectively based on medical charts. For statistical analysis, Chi-squre test was used. RESULTS: All patients undergone emergency operations, in which male to female ratio was 1.79: 1, with its mean age of 4.05. 19 patients (49%) were perforated and fever developed more frequently in perforating group, but leukocytosis was not significant. Delayed preoperative duration was associated with perforation rate significantly. All complications were occurred in perforating group. CONCLUSION: To decrease perforation rate and complications, early diagnosis and management are necessary to avoid delaying preoperative time.

Trauma-related Acute Spigelian Hernia in Right Upper Abdomen

Trauma-related spigelian hernia is a rare event that has been reported only sporadically. Because of its rare nature and nonspecific physical findings, its diagnosis is difficult. This hernia most commonly presents at the level of the semicircular line known as the arcuate line. A 70-year-old man was admitted after overturn of his cultivator. A scratch wound surrounding a cutaneous sign of the cultivator handlebar impact was evident on his right upper abdominal wall. Trauma-related spigelian hernia occurred in the site of the handlebar impact. We report this cases of trauma-related spigelian hernia that was treated by primary repair with a brief review of the literature.

Intestinal Obstruction Due to Incarcerated Hernia at CAPD Catheter Insertion Site

Patients who have undergone peritoneal dialysis can frequently experience abdominal wall complications, such as hernia due to increased intraabdominal pressure and peritoneal leakage. However, no case of incarcerated abdominal wall hernia through catheter insertion site of CAPD has yet been reported Recently the authors experienced a case of intestinal obstruction due to an incarcerated hernia at the catheter insertion site of CAPD. We report this case and present a literature review.

Idiopathic Perforated Cecitis Mistaken as Perforated Appendicitis

The cecal perforation is very rare in pediatrics. Our center has experienced a 7-year-old girl with idiopathic perforated cecitis. The surgeon couldn't differentiate perforated cecitis from perforated appendicitis because of anatomical location, incidence and ambiguous radiologic result when this patient was admitted to our clinic due to RLQ pain.

Traumatic Diaphragmatic Ruputure: 4-Year Clinical Experience

PURPOSE: A traumatic diaphragmatic rupture (TDR) is a diagnostic challenge and the associated injuries determine the outcome in those diagnosed early. A TDR has long been considered to be a marker of the severity of injury with an average reported Injury Severity Score (ISS) between 31 and 50. This report reviewed the TDR cases in order to emphasize the method and timing of the diagnosis, associated injuries and the outcome. METHODS: A retrospective analysis was performed on 30 patient treated for TDR between August 1998 and september 2002. RESULTS: The mean age of the patients was 33.4 years and the injury predomiantly affected males (male: female=2: 1). Blunt trauma by TA was the most common cause of the TDR (25 patients). The ruptured sites were on the left in 22 cases and on the right in 8 cases. The most common symptom was chest pain (23 cases) followed dyspnea (21 cases). Liver injuries and a pneumo-hemothorax were the most common associated injuries. The mean CRAMS scale was 6.47 and Injury Severity Score (ISS) was 18.93. Eighteen TDR cases were suspected based on the abnormal chest X-ray findings. Nineteen cases underwent surgery within 6 hours after the trauma (early diagnosis). Although many complications occurred in 11 cases, there were no lethal complications. The mean size of the diaphragmatic rupture was 9.77 cm and an intraabdominal organ herniation had not occurred in ruptures smaller than 6 cm. Surgical repair of the diaphragm was performed via a laparotomy in 20 cases and thoracotomy in 7 cases. A left side TDR was preferred to a laparotomy whereas a right sided TDR was preferred to a thoracotomy. Pulmonary complications (atelectasis, pneumonia, pleural effusion) occurred in 14 cases postoperatively. CONCLUSION: The patient's complaints and physical findings were not a reliable indicator of the diagnosis, but usually a manifestation of the associated injuries. A suspicion and routine chest X-ray was the most reliable diagnostic tool, even though the chest X-ray was normal in 12 cases. A high rate of early diagnosis can be achieved using an aggresive investigation protocol, suspicion and a combined radiologic evaluation in multiple trauma patients. Although pulmonary complications occurred in the early diagnosed cases, lethal complications and long term sequela were directly related to the time of diagnosis. The higher ISS had many complications (11 cases) but there were no lethal complications, long term sequela.

Strangulated Obturator Hernia: Mesh-Plug Technique

Although obturator herniae are rare, they are associated with a high mortality, as diagnosis is often delayed and the condition tends to occur in the elderly. The preoperative diagnosis is difficult because of nonspecific symptoms and sign. They often produce a small bowel obstruction. The treatment is always surgical. Several repair techniques have been described: a sac ligation alone, a direct suture repair, and the use of autologous tissue or prosthetic repair. Recently, the placement of permanent mesh prostheses, in a clean contaminated operative field, has been performed due to the minimal wound-related morbidity and patient mortality. Thus, utilization of a permanent mesh in an obturator hernia is a new, simple and effective method for repair. Two cases of a strangulated obturator hernia were experienced in elderly women. The peritoneal cavity was not overly contaminated, with only necrotic foci on the herniated small bowel wall noted. A segmental resection of the small bowel was performed. Consequently, the hernia defect was closed with mesh- plug between the peritoneum and periosteum of the obturator foramen. Here, two cases of obturator herniae treated by use of a mesh-plug are reported, with a brief review of the literature.

Comparison of Laparoscopic Cholecystectomy and Minilaparotomy Cholecystectomy

BACKGROUND: Cholecystectomy is the standard treatment for gallbladder stones and at present is performed in minimally invasive procedures. There are several advantages to a laparoscopic cholecystectomy, so now it is a popular procedure for use in a cholecystectomy. Also, a minilaparotomy cholecystectomy is an alternative method to a traditional open cholecystectomy and results in a smaller incision than a traditional open cholecystectomy. METHODS: We analyzed outcomes following laparoscopic and minilaparotomy cholecystectomy. 74 patients with gallstones were included. 45 patients were treated by a laparoscopic cholecystectomy and 29 patients were treated by a minilaparotomy cholecystectomy. RESULTS: Compared to the minilaparotomy cholecystectomy, the laparoscopic cholecystectomy resulted in a shorter mean hospital stay, a faster mean time to diet, and a longer mean operating time. During the first postoperative 24 hours more analgesics were used in the minilaparotomy cholecystectomy than in the laparoscopic cholecystectomy, and the laparoscopic cholecystectomy was more expensive than the minilaparotomy cholecystectomy. Postoperative complications occurred in 3 patients receiving a lapaaroscopic cholecystectomy and 1 patient receiving a minilaparotomy cholecystectomy. Conversion from a laparoscopic cholecystectomy to a traditional open cholecystectomy was necessary in 2 patients; no conversion to a traditional cholecystectomy was necessary in the minilaparotomy cholecystectomy. CONCLUSIONS: This study has proven the advantages of a laparoscopic cholecystectomy to be shorter hospitalization, less pain, and better cosmetic effect. Also, a minilaparotomy cholecystectomy has the advantages of a laparoscopic cholecystectomy and can be performed more safely.