One-year experience with single incision laparoscopic cholecystectomy in a single center: without the use of inverse triangulation

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is generally performed with the use of inverse triangulation. In this study, we performed 3-channel or 4-channel SILC without the use of inverse triangulation. We evaluated the adequacy and feasibility of SILC using our surgical method. METHODS: We retrospectively reviewed our series of 309 SILCs performed between March 2014 and February 2015. RESULTS: Among 309 SILCs, male were 148 and female were 161 patients, mean age was 48.7 +/- 15.3 years old and mean body mass index was 24.8 +/- 3.8 kg/m2. Forty patients had previously undergone abdominal surgery including 6 cases of upper abdominal surgery. SILC after percutaneous transhepatic gallbladder (GB) drainage was completed in 8.7% of cases. There were 10 cases of emergency SILC. SILC was performed for noncomplicated GB including symptomatic GB stone and polyp in 66.7% of cases, acute cholecystitis in 33.3%. Overall, 96.8% of procedures were successfully completed without additional port. The reason for addition of an extra port or open conversion included technical difficulties due to severe adhesion and bleeding. The mean operating time was 60.7 +/- 22.3 minutes. The overall complication rate was 4.8%: 9 patients of wound seroma, 1 case of bile leakage from GB bed, 4 cases of intra-abdominal abscess or fluid collection, and 1 case of incisional hernia were developed. There was no case of common bile duct injury. CONCLUSION: Our surgical method of SILC without the use of inverse triangulation is safe, feasible and effective technique.

Laparoscopic treatment for post-cholecystectomy Mirizzi syndrome

The remnant cystic duct or gallbladder neck calculus may rarely result in post-cholecystectomy Mirizzi syndrome. Various managements have been proposed for the treatment of post-cholecystectomy Mirizzi syndrome. Some previous cases of post-cholecystectomy Mirizzi syndrome have been managed with open cholecystectomy and endoscopically. We report a case of a laparoscopic stone removal of post-cholecystectomy Mirizzi syndrome that developed 7 months after laparoscopic cholecystectomy. To our knowledge, this is the first case of laparoscopic management of post-cholecystectomy Mirizzi syndrome. The mechanism, diagnosis and treatment of post-cholecystectomy Mirizzi syndrome are discussed.

Laparoscopic Right Hemicolectomy and Cholecystectomy for a Cholecystocolic Fistula

A cholecystocolic fistula (CF) is an uncommon complication of the gallbladder and colonic disease. We report a case of a CF that was successfully managed by using a laparoscopic right hemicolectomy and cholecystectomy. A 49-yr-old woman was admitted to the Department of Internal Medicine because of intermittent and progressive right upper quadrant pain. She was obese (body mass index: 34 kg/m2) and had a previous history of three abdominal surgeries. She was diagnosed with a CF by using abdominal computed tomography. The fistula between the gallbladder and the hepatic flexure of the colon was also characterized by using technetium-99m diisopropyl iminodiacetic acid ((99m)Tc-DISIDA) cholescintigraphy, a double-contrast Barium enema, and colonoscopy. Multiple polyps with severe inflammation were observed around the orifice of the fistula. Because of the risk of malignancy and appendicolith on CT, a laparoscopic en block excision of the gallbladder and the right colon following adhesiolysis was performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. This case shows that the laparoscopic combined resection is safe and effective in the experienced hands of the laparoscopic surgeon even though a CF has traditionally been considered as a contraindication to laparoscopic surgery. While the incidence of successful management of biliary-enteric fistulas through laparoscopic repair is increasing, this is the first report of a laparoscopic combined resection of a CF in an obese patient with severe intraabdominal adhesion.

Clinical Usefulness of the Methods of Gallbladder Bed Dissection for Treating Acute Cholecystitis / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic cholecystectomy (LC) for treating acute cholecystitis (AC) is a technically demanding procedure even for experienced surgeons. The purpose of this study is to evaluate the clinical usefulness of the methods of gallbladder bed dissection for patients with acute cholecystitis. METHODS: We reviewed the medical records of 74 patients who were admitted for AC and they underwent early LC with ultrasonic shears dissection (UD) (n=40) or monopolar electrocautery dissection (MD) (n=34) at Kangnam Sacred Heart Hospital from August 2006 to December 2008. We compared many variables between the two methods. RESULTS: The mean operative time in the LC group with UD was 48.3 minutes versus 42.8 minutes for the MD group (p=0.163). The conversion rate was 5.0%, and the postoperative morbidity rate was 12.5% in the UD group, versus an 8.8% conversion rate and an 8.8% morbidity rate in the MD group (p=0.426 and 0.254). CONCLUSION: The use of UD in the dissection of the gallbladder bed has no specific advantage over MD for treating patients with acute cholecystitis, but further investigations are required to confirm this.

MALT Lymphoma of Ocular Adnexa: A Case Report

PURPOSE: Lymphoma originated from mucosa associated lymphoid tissue(MALT) is most common in gastrointestinal system, and rarely found in salivary gland, thyroid, bronchus or orbit. We experienced a case of MALT lymphoma which was originated from conjunctiva and involving lower eyelid without metastasis. METHODS: A 40-year-old man suffered palpable mass on right lower eyelid without pain. Orbital computed tomographic and ultrasonographic findings showed a conical mass(1.9x1.2x0.9cm size) inside lower eyelid. The mass was completely excised under local anesthesia and histopathological examination was followed. RESULTS: Microscopic finding showed a multiple follicular colonization. In the follicle, small lymphocytes and plasma cells differentiated to centrocyte-like cell, monocyte B cell, plasma cell were diffusely infiltrated. Immunophenotyping was preformed on fixed section. The majority of the small cells were immunoreactive for the B cell marker CD20. Based on the typical histological findings supported by immunostaining, the mass was defined as MALT lymphoma. After excision, SPECT, abdominal CT was carried out and there were no evidence of extraorbital disease. CONCLUSION: Biopsy and pathological examination should be performed in patients who complain palpable mass on lower eyelid because of possibility of MALT lymphoma. Although MALT lymphoma is rarely metastasized, it is necessary to evaluate the extraorbital involvement using SPECT or other radiologic exams. For detecting extraorbital involvement, periodic follow-up examination is need.

Small bowel obstruction caused by an anomalous congenital band in an infant / 소아과

Intestinal obstruction is not uncommon in infants. The common causes of intestinal obstruction in the neonatal period are Hirschsprung disease, intestinal atresia, meconium ileus, and intussusception. However, small bowel obstruction caused by a congenital band is very rare. We report a 27-day-old baby who was admitted with abdominal distension and fever. The abdominal X-ray revealed massive bowel dilatation and the contrast gastrografin enema suggested a distal small bowel obstruction. The explolaparotomy showed small bowel entrapment due to an unusual anomalous congenital band.

Duodenal Perforation in a Child with Henoch- Schoenlein Purpura

Henoch-Schoenlein purpura is predominantly a childhood disease with good prognosis. It is characterized by nonthrombocytopenic purpura, arthritis, arthralgia, gastrointestinal symptoms and glomerulonephritis. Abdominal pain is the most common gastrointestinal symptom, however, some patient with Henoch-Schoenlein purpura have gastrointestinal major surgical complication such as intussusception, bowel infarction, necrosis, stricture and perforation. We report a case of duodenal perforation in a 6-year-old boy with Henoch-Schoenlein purpura, being treated with corticosteroids.

A Clinical Analysis of Abdominal Stab Injuries

PURPOSE: This study was done to evaluate the incidence, type of injury, medical consequences, mortality, and prognostic factors associated with stab wounds in patients who visited Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea. METHODS: A retrospective analysis of the clinical data of 40 patients with abdominal stab wounds who visited Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea from January 1, 2000 to December 31, 2004. RESULTS: 1) The most prevalent age group was patients in their the twenties to fourties (77.5% of all patients), and average age of the patients was 39.3 years. The male-to-female ratio was 2.07:1. 2) The external site of stab wounds was most commonly the periumbilcal area of the abdomen (14 cases, 33.3%). 3) The most commonly injured organs were the liver and the stomach (10 cases each, 16.9%). 4) Operations were performed on all 40 patients, with 9 (22.5%) negative operation findings. 5) Death occurred in 5 cases (12.5%). 6) The trauma indices of the death group were TRISS 51.9%, RTS 3.6 points, and APACHE II 23.0 points. 7) The average transfusion amount of the death group was 13.8 pints CONCLUSION: These data suggest that the transfusion amount and the trauma index of abdominal stab injuries may be statistically significant factors for predicting mortality.

A Clinical Analysis of Abdominal Stab Injuries

PURPOSE: This study was done to evaluate the incidence, type of injury, medical consequences, mortality, and prognostic factors associated with stab wounds in patients who visited Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea. METHODS: A retrospective analysis of the clinical data of 40 patients with abdominal stab wounds who visited Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea from January 1, 2000 to December 31, 2004. RESULTS: 1) The most prevalent age group was patients in their the twenties to fourties (77.5% of all patients), and average age of the patients was 39.3 years. The male-to-female ratio was 2.07:1. 2) The external site of stab wounds was most commonly the periumbilcal area of the abdomen (14 cases, 33.3%). 3) The most commonly injured organs were the liver and the stomach (10 cases each, 16.9%). 4) Operations were performed on all 40 patients, with 9 (22.5%) negative operation findings. 5) Death occurred in 5 cases (12.5%). 6) The trauma indices of the death group were TRISS 51.9%, RTS 3.6 points, and APACHE II 23.0 points. 7) The average transfusion amount of the death group was 13.8 pints CONCLUSION: These data suggest that the transfusion amount and the trauma index of abdominal stab injuries may be statistically significant factors for predicting mortality.

Gastroduodenal Intussusception Secondary to a Gastric Carcinoma

Gastroduodenal intussusception is an extremely uncommon condition caused by the prolapse of a gastric tumor into the duodenum, with the subsequent invagination of a portion of the stomach wall. The lead point of the intussusception is usually a benign gastric tumor, with only a small number attributed to gastric carcinomas. Both gastroduodenal intussusception itself and a gastric carcinoma as the lead point are extremely rare. The authors present a case of gastroduodenal intussusception caused by a Borrmann type I gastric carcinoma. This case can be classified as a partial lateral invagination with a grade II internal mechanism.

Stercoral Perforation of the Colon

A stercoral perforation of the colon is a very rare condition, which results from stercoral ulcers due to severe, prolonged constipation, and has a very high mortality rate. Herein is presented four cases of stercoral perforation of the sigmoid colon. All the patients were female. They had long standing and severe constipation, with peritonitis, prior to admission. Plain chest or abdominal X-rays revealed the presence of abdominal free air in all cases, and so emergent operations were undertaken. Fecalomas were found in the colon or abdominal cavity, with round and spherical shaped perforated sites. Microscopically, the edges of the ulcers were compressed with the accumulation of lymphocytes. A resection of the perforated colon with a proximal colostomy was performed in one case, a primary closure of the perforated colon and a proximal colostomy in another and a Hartmann's colostomy in the remaining two cases.

Early Results of Transilluminated Powered Phlebectomy for Primary Varicose Vein of the Lower Limbs

PURPOSE: To determine the efficacy and safety of endoscopic resection and ablation of superficial varicose vein using a powered vein resector and irrigated illuminator. METHODS: Forty-three limbs in 29 patients were involved in our hospital study. The clinical records between August 2002 and February 2004 were reviewed. All patients were treated with a minimally invasive, powered vein resecting device, using cutaneous transillumination and tumescent fluid under general or spinal anesthesia. RESULTS: The 29 varicose vein patients were composed, (19 men (65.5%) and 10 women (34.5%), with a mean age of 56.9 years. The most common symptom or sign of varicose vein was an unsightly vein (15 patients, 51.7%). Fifteen unilateral (5: right, 10: left) and 14 bilateral operation for varicose veins were performed. The mean operative time, number of skin incisions and length of hospital stay were 34.2 minutes, (ranging from 26 to 58, 3.2 sites, (ranging form 2 to 6) and 3.3 days, (ranging from 2 to 6). Postoperative complications occurred in 12 limbs (27.9%), including skin perforation (1 limb, 2.3%), wound abscess (1 limb, 2.3%), cellulitis (1 limb, 2.3%), lower limb pain (4 limbs, 9.3%), edema (2 limbs, 4.7%), hematoma (1 limb, 2.3%), remaining varicose vein (1 limb, 2.3%) and paresthesia (1 limb, 2.3%). CONCLUSION: This study showed that the TIPP (TriVexTM) technique for varicose vein removal was swift and efficacious. When performed by trained surgeons the complication rates of the technique were comparable with those of conventional surgery, with the advantages of a trend toward reduced operating times in extensive varicose vein, and significantly fewer incisions.

A Case of Gastrocolic Fistula by Primary Colon Cancer

A gastrocolic fistula is a fistulous communication between a segment of colon and the stomach. It is a rare complication and is caused most commonly by a carcinoma of the colon or the stomach. Among the less common causes of a gastrocolic fistula are a benign gastric ulcer, chronic ulcerative colitis, Crohn's disease, a carcinoid tumor, syphillis, an intraabdominal abscess, a lymphoma, trauma, intestinal tuberculosis, and iatrogenic factors. Recently, the incidence of gastrocolic fistulas has decreased due to earlier diagnosis and treatment of stomach and colon cancer. The classic triad of symptoms are lienteric diarrhea, feculent vomiting, and foul eructations, but all patients do not necessarily present with these symptoms. A gastrocolic fistula is usually diagnosed by using a barium enema, but occasionally can be detected by using an upper gastrointestinal series or endoscopy. Here, we report experience with a fistula between a cancerous transverse colon and the stomach and give a review of the literature.

A Case of Gastric Mucinous Adenocarcinoma Presenting as a Characteristic Mucin Pool / 대한소화기내시경학회지

Mucinous adenocarcinoma is a rare histologic type of gastric carcinoma. Most mucinous gastric carcinoma is diagnosed by histology after surgical resection. However, in this report, we preoperatively predicted the type of a tumor (mucinous type) from its characteristic endoscopic finding. An endoscopic examination showed a cauliflower-like mass on the upper body of the posterior wall. At first we could not find the mass because it was covered with a thick mucin-like substance. After gastric lavage and mucin aspiration we found a tumor mass which was surrounded with a characteristic mucin pool. Abdominal CT showed a 6 cm sized-mass connected with the gastric fundus. Total gastrectomy with esophagojejunostomy was performed. The pathology of the tumor proved to be a mucinous adenocarcinoma.

A Clinical Analysis of Thyroglossal Duct Cyst and Sinus

PURPOSE: Anomalies in the thyroglossal duct are the most common midline, or paramedian cervical lesions of congenital origin. Presenting as a thyroglossal duct cyst (TGDC) or a thyroglossal duct sinus (TGDS), they are found in all age groups. This clinical study was intended to elucidate the clinical characteristics, and the outcomes, of surgical treatment of these anomalies. METHODS: Between January 1992 and May 2002, 91 patients underwent surgery for a TGDC or a TGDS at 4 hospitals affiliated to Hallym University. The demographics of the patients, the clinical characteristics of the lesions, and the outcomes of the treatments were retrospectively evaluated. These characteristics were evaluated according to age groups; younger than 15 (38 patients) and older than 15 (53 patients) years. RESULTS: The male to female ratio was 1.67: 1 (It is better to give the actual figures.), with the first decade showing the highest incidence in the age distribution (33%). Painless masses (83.6%) were the most common presenting symptom, with most symptoms having been manifest for less than 1 year (67%). TGDCs were 90% and TGDSs were 10%. There were 62 cases of infrahyoid and 18 of suprahyoid lesions, with 80 cases on the midline and 11 on the paramedian within 2 cm from the midline. Of the paramedian lesions, 2 cases were in the younger group and 9 were in the older group. This tendency of laterality in the location by age group showed no statistical significance (p=0.172). All the patients underwent a Sistrunk operation, and one experienced a recurrence. CONCLUSION: This study justified the Sistrunk operation as the treatment of choice for anomalies of the thyroglossal duct. The lateral lesions occurred in the old age groups more frequently. A careful approach is needed with paramedian cervial lesions in adults to avoid the loss of the proper treatment of possible hidden congenital lesions.

A Case of Cecal Volvulus Diagnosed with Abdominal Computed Tomography

Cecal volvulus is a rare disease of the colon, which occurs in less than 2% of adult intestinal obstruction cases. Precipitating factors can be identified in some patients, including adhesions, a recent abdominal operation, congenital bands, pregnancy, violent exercise, malrotation, obstructing lesions of the left colon and colonoscopy, etc. A right colectomy is a definitive treatment for the best long term control of symptoms, and is the treatment of choice when gangrenous changes are present in the bowel. However, in the presence of viable bowel, the preferred treatment is a controversial matter, with options including; detorsion, cecopexy and cecostomy, etc. We experienced a case of cecal vovulus, which had been treated for COPD at ICU. A diagnosis was made with abdominal computed tomography, and a right hemicolectomy was performed.

Multiple Ulcerating Malignant Lymphoma of the Gastrointestinal Tract with Perforation

Malignant lymphoma of the gastrointestinal tract is a rare lesion, which comprises 1~4% of the malignant neoplasms of the gastrointestinal tract. Abdominal pain and weight loss are the most common symptoms and an abdominal mass, the most common physical finding. This tumor is often discovered at a late stage; a diagnosis should be done on all patients undergoing an emergency operation for an obstruction, hemorrhage, or perforation. We report a case of a multiple ulcerating malignant lymphoma of the gastrointestinal tract with perforation in a 60 year-old male. The patient visited our hospital because of a sudden onset of acute abdominal pain. The operative finding was multiple masses on the small bowel, sigmoid colon, and stomach, plus multiple perforations of the small bowel. We performed a multiple small bowel segmental resection and an anastomosis at the site of the perforated lesion. The pathologic evaluation diagnosed it as a malignant lymphoma and the patient was treated with cyclophosphamide, adreiamycin, and vincristine. We report this rare disease with a review of the literature.

Intussusception due to Diverticulum of Ileocecal Area: A case report / 대한소아소화기영양학회지

Intussusception is a frequent cause of bowel obstruction in the first five years of life and it is one of the most common surgical emergencies in infancy and early childhood. The age of five months child was administered in Department of Pediatrics of Chunchon Sacred Heart Hospital. His main symptoms were vomiting and high fever for three days. Abdominal sonography, air reduction and abdominal computerized tomography (CT) were performed and the conclusion of these study was intussusception due to cyst mass lesion; duplication cyst, mesenteric cyst or Meckel's diverticulum. He was transferred for operation. We had performed laparotomy for reduction of the intussusception. Operative findings revealed ileocolic type of intussusception due to cystic tumor on ileocecal valve that was invaginated into the cecum, and hyperplasia of the Peyer's patch were seen. But we failed manual reduction because of the tumor in the ileocecal area. So we had performed partial resection of the ileocecum. Diverticulum of the ileum was confirmed by pathologic examination. We experienced unusual cause of the intussusception. So we report this case with a review of the literatures.

Osteogenic Sarcoma of the Breast

Osteogenic sarcoma is a rare breast tumor. The first report of a malignant mammary neoplasm composed of bone and cartilage was that of Bonet in 1700. Meanwhile in Korea, Kim et al reported one case of osteosarcoma of the breast in 1999. A 44 year old woman visited our hospital because of a mass on her right breast. The mass was fixed on the skin and 5 5 cm in size. Following a frozen biopsy result of malignancy. A modified radical mastectomy was performed. The tumor was confirmed histologically and immunohistochemically as an osteogenic sarcoma. This study presents one case of an osteogenic sarcoma of the breast, and the report of this rare breast tumor is accompanied by a review of the literature.

Superior Mesenteric Artery Syndrome: Report of three cases

Superior mesenteric artery syndrome is a rare clinical disease in Korea. The authors experienced three cases of the superior mesenteric artery syndrome. All of patients complained of continuos bilious vomiting, epigastric discomfort, epigastric fullness, and weight loss. The superior mesenteric artery syndrome was diagnosed preoperative, by using physical examination, gastrofiberscopy, upper gastrointestinal series, abdominal computerized tomography (CT), and spiral CT angiogram. We performed a Roux-en-Y duodenojejunostomy. We measured the angle between the aorta and that superior mesenteric artery by using a spiral CT angiogram. The angles were 10o, 11o, and 11o. Postoperatively they were improved. A spiral CT angiogram was a noninvasive method of diagnosing the superior mesenteric artery syndrome compared with a femoral angiography. The Roux-en-Y duodenojejunostomy was the proper method of treatment for the superior mesenteric artery syndrome.