Gastrointestinal Stromal Tumors - Diagnosis and Surgical Treatment.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, previously classified as leiomyomas, leiomyosarcomas, leiomyoblastomas or schwannomas. They are now recognized as a distinct entity with origin in the mesodermal interstitial cell of Cajal, cells that express the c-KIT protein (tirozine kinase receptor). The definitive diagnosis is established by immunohistochemistry, more than 95% of GISTs being positive for CD117. Despite the major progress of chemotherapy, the treatment of choice is surgery, and it implies the complete resection of the tumor. The evolution of these tumors is unpredictable and the prognosis depends on localization, tumor size and mitotic index. Benign tumors have an excellent prognosis after surgery, with a 5 year survival of 90%, while malignant tumors resistant to radiotherapy and chemotherapy have a dismal prognosis even after surgical resection, with a median survival of 1 year. We studied a group of 15 patients diagnosed with TSGI in the Surgery Clinic of the œProf. Dr. Agrippa Ionescu Clinical Emergency Hospital, between 2003 and 2013, following the particularities of presentation, diagnosis and treatment, with focus on the prognostic factors according to available literature data.

Robotically performed total mesorectal excision for rectal cancer.

BACKGROUND: Rectal cancer is an important health problem, due to the increasing number of new cases and the quality of life issues brought forth by surgical treatment in these patients. AIM: The aim of the study was to analyse the results of robotic surgery in the treatment of lower and middle rectal cancer,locations in which TME is performed. MATERIAL AND METHOD: Patients diagnosed with and operated on for rectal cancer by the means of robotic surgery between 2008-2012 at the Fundeni Clinical Institute were retrospectively analysed. RESULTS: A number of 117 patients with rectal cancer were operated on by robotic surgery, of which 79 (67.52%) were submitted to total mesorectal excision (TME). The most frequently performed surgery was low anterior resection, followed by rectal amputation through abdominoperineal approach.Anastomosis fistula was observed in 9 (11.39%) patients. Local recurrence was encountered in 2 (2.53%) of the robotically performed surgeries. CONCLUSIONS: 1. Robotically assisted total mesorectal excision is feasible, safe and can be performed with a small number of complications and a low local recurrence rate; 2. The main advantages are oncological safety and quality of life; 3.Conversion to open surgery is rarely encountered; 4. Protection loop ileostomy existence allows avoiding reintervention in case anastomotic fistula occurs in patients with low anterior resection. 5. Robotic surgery may become gold standard in the surgical treatment of rectal cancer.

Large oesophageal epiphrenic diverticulum resected by transhiatal robotic-assisted approach -- case report.

INTRODUCTION: Epiphrenic diverticula (ED) represent about 20% of oesophageal diverticula. They are considered to be pulsion diverticula, characterized by out pouchings of the oesophageal mucosa originating in the distal 10 cm of the oesophagus and are frequently associated with spastic oesophageal dysmotility. The most frequent clinical manifestations of ED are dysphagia, regurgitations and chest pain. Only symptomatic diverticula should be treated by surgery. The surgical procedure can be performed minimally invasively by robotic approach and consists of diverticulectomy,hiatus calibration and an antireflux procedure, usually adding an esophagomiotomy as well. CASE-REPORT: We present the case of 43-year-old male patient who was admitted for a four-month history of epigastric pain, pyrosis and regurgitations. Preoperative investigation shave shown an epiphrenic diverticulum 6 cm large in diameter.A robotic-assisted transhiatal diverticulectomy with a linear endostapler, hiatal calibration and a Nissen-Rossetti fundoplication were performed using a three-arm da Vinci Robotic System. Operative time was 150 min. Postoperative course was uneventful and the patient was discharged on postoperative day 9, without complications. Ten days later,he came back and was readmitted under emergency status for right chest pain, dyspnoea and fetid breath, being diagnosed with a right empyema secondary to a delayed fistula of the oesophageal suture line. A right minimal pleurotomy and pleural drainage under local anaesthesia were performed and an intravenous antibiotherapy was started with complete remission of symptomatology, the patient remaining asymptomatic after 18 months of follow-up. CONCLUSIONS: Robotic approach is a feasible and safe minimally invasive surgical option in the treatment of selected cases of ED. We consider transhiatal abdominal robotic approach possible in almost all cases of ED, regardless of size,thus avoiding thoracic approach and its possible major complications.The most common serious complication after surgery of ED is post diverticulectomy suture line fistula, but if properly and rapidly diagnosed it could be conservatively treated with very good results.

Laparoscopic treatment in achalasia of the cardia.

BACKGROUND: Achalasia, although a rare disease (an incidence of 1 100 000 individuals each year) is one of the common causes of motor dysphagia and is characterized by loss of peristalsis in the esophageal body and lack of relaxation of the lower esophageal sphincter. AIM: The aim of our study was to perform a clinical,therapeutic and evolution evaluation in patients diagnosed with achalasia and operated in our department between 1997 and 2013. MATERIAL AND METHODS: We performed a retrospective study using the clinical charts, operatory protocols, imagistic and video database of the 17 patients with achalasia operated in our department. RESULTS: We encountered an equal repartition in women and men and a predominance of urban provenience. Ages were between 24 and 86 years (with an average age of 51). There were two cases of recurrent achalasia at 2, respectively 5 years after the first operation. In all cases, Heller myotomy was used, with the addition of a Dor fundoplication in 12 cases and Toupet fundoplication in five cases, as an antireflux procedure. Mean operation time was 117.6 minutes.There were three iatrogenic perforations of the esophageal mucosa, all of them recognized and treated in the same operative time. No postoperative complications related to the Heller-Dor Heller-Toupet procedure were encountered.The follow-up was between 3 and 72 months. CONCLUSIONS: Laparoscopic approach in the treatment of achalasia provides the advantages of minimally invasive surgery, but also and very important, a good visualization of the abdominal esophagus and gastroesophageal junction.Heller esocardiomyotomy is usually associated with anantireflux procedure. A Dor fundoplication is generally used,although the Toupet fundoplication may also be used with the same advantages. It is important to monitor these patients on a yearly basis, knowing the risk of dysplasia carcinoma in achalasia.

Acute mesenteric ischemia after heart surgery.

INTRODUCTION: Acute mesenteric ischemia (AMI) is a rare but very severe complication of heart surgery, due especially to the delay in setting the correct diagnosis and choosing the appropriate treatment. There are 4 types, but the most frequent is nonocclusive mesenteric ischemia (NOMI). The main mechanism is represented by great decrease or maldistribution of the splenic blood flow, with negative impact on the integrity of the intestinal mucosa, bacterial translocation and multiorganic failure. MATERIAL AND METHOD: We present a retrospective study conducted on patients who underwent open heart surgery with cardiopulmonary bypass with non-pulsatile flow. 4 cases of angiographically confirmed NOMI (non-occlusive mesenteric ischemia) were identified. When, based on clinical examination and laboratory findings, acute mesenteric ischemia was suspicioned, superior mesenteric artery angiography was performed via the femoral artery. RESULTS: The main risk factors were represented by: age over 70 years old, left ventricle ejection fraction (LVEF) 35%,aortic clamping time 100 min., chronic kidney failure,counter-pulsation balloon implant, inotropic medication use,like levosimendan, use of blood components 1 unit of erythrocyte mass. Clinical signs were nonspecific. All patients presented hypoventilation, arterial hypotension, oliguria and,from a biological standpoint, metabolic acidosis and leucocytosis. Superior mesenteric artery angiography was the investigation method of choice. Treatment approach was initially medical, followed by resection of the intestine.Mortality was 100%. CONCLUSIONS: Acute mesenteric ischemia is a rare but very severe complication in cardiac surgery. It is primordial that the main risk factors be known, and in case of diagnosis suspicion, that it be set as early as possible, along with immediate initiation of an appropriate course of treatment.

Occult thyroid carcinoma in our experience -- should we reconsider total thyroidectomy for benign thyroid pathology?

BACKGROUND: The reported incidence rate of occult thyroid carcinoma in patients operated for benign thyroid pathology has been much higher than expected in the last years,especially for multinodular goitre, which raises the question about which should the proper surgical management for these cases be. AIM: To assess the incidence rate of OTC in a single medium volume surgical center and to establish the correct indication for initial surgical management, as well as to identify the benign thyroid pathology most frequently associated with OTC. We also reviewed the relevant scientific literature on this topic. MATERIAL AND METHOD: We conducted a retrospective study in the General Surgery Clinic of "Prof. dr. Agrippa Ionescu" Clinical Emergency Hospital, Bucharest, on a series of 145 patients who underwent surgical interventions for preoperatively diagnosed benign thyroid pathology over a ten year period, between 1st January 2002 - 31st December 2012. All cases of known thyroid cancer were excluded. RESULTS: Incidence rate of occult thyroid carcinoma in our series was 6.9 % (10 out of 145 patients), 80 % of them being diagnosed with multinodular goitre and two cases (20 %) with Hashimoto's lymphocytic thyroiditis. 6.8 % of all patients with multinodular goitre were found to present occult carcinoma,but this association was without statistical significance(p 0.05). Incidence rate of occult cancer among patients with Hashimoto thyroiditis was proved to be as high as 28.6%,statistically significant (p=0.020). The mean size of postoperatively diagnosed occult microcarcinoma was 7 mm, ranging between 3 mm and 14 mm, 90% of them being smaller than 1cm. Histologically, papillary microcarcinoma was found in all cases. The mean age of the patients diagnosed with occult microcarcinoma was 47.8 years with majority of the female gender. The most frequent operation performed was total thyroidectomy (70.8%). Overall morbidity in our series was 6.9% with a 0.7 % mortality rate (1 case). CONCLUSIONS: In our opinion, primary total thyroidectomy should be performed as the procedure of choice for the most part of preoperatively diagnosed benign thyroid pathology and particularly for multinodular goitre and Hashimoto thyroiditis,in order to radically resect all possible foci of aggressive thyroid microcarcinomas.Abbreviations and Acronyms: OTC (Occult Thyroid Carcinoma), PTMC (Papillary Thyroid Microcarcinoma); TT(Total Thyroidectomy), MNG (Multinodular Goitre), GD(Graves' disease), TNG (Toxic Nodular Goitre), FNAB(fine-needle aspiration biopsy).

The surgical treatment for Crohn's disease.

INTRODUCTION: Crohn's disease is a chronic idiopathic medical and surgical disease, in which the transmural intestinal inflammatory process frequently leads to complications such as strictures or fistulae. The disease is considered to be the result of an imbalance between the proinflammatory mediators and the anti-inflammatory ones; it can be localized on any segment of the gastrointestinal tract, but it especially affects the terminal ileum. The purpose of the study is to assess Crohn's disease from the point of view of the complications requiring surgical treatment, the manner in which they are solved, as well as the postoperative evolution. MATERIAL AND METHOD: we followed retrospectively the patients hospitalized and operated in our department during the period January 2001 - December 2011. We examined the clinical observation charts, the paraclinical investigations, the surgical protocols and the histopathological results. RESULTS: the 11 patients included in the study underwent 13 surgical interventions. Their ages were comprised between 16 and 67, the average age being 42.9. The men women ratio was 7 4 (1.75); the interventions performed were segmental enterectomies, right ileo- hemicolectomy, ileotransverse anastomosis, an exploratory laparotomy and an exploratory laparoscopy. CONCLUSIONS: the purpose of the treatment of Crohn's disease is to obtain the best possible clinical, laboratory and paraclinical control of the inflammatory process with the least adverse reactions to the medication. The surgical indications for the treatment of the disease are imposed by severe complications such as perforation, stenosis, fistulisation and even malignancy. Consequently, although Crohn's disease is a chronic disease with many relapses, the correct medical and surgical treatment helps patients to maintain a reasonable quality of life, with a good prognosis and a very low mortality rate.

[Unique duodenal hamartomatous polyp--case report]. / Polip hamartomatos duodenal unic--prezentare de caz clinic.

Duodenal tumors are very rare tumors, with the lower incidence among the tumors of the small bowel, whose frequence is less than 5 % of all digestive tumors. In most of the cases these tumors remain asymptomatic, sometimes the entire life. When they become symptomatic, their first manifestation is the loss of digested blood (melena), secondary anemia and obstructive symptomatology. Early diagnosis of these tumors is difficult because of the unsystematic symptomatology and becomes easy when the complications appear. In most of the cases the diagnosis is establish by the superior digestive endoscopy, followed by barium contrast studies, CT and ultrasound. We present a case of duodenal hamartomatous polip, unique, at the level of D3, in a female patient 66 years old, addressing to our service for superior digestive hemorrhage exteriorizated by melena, secondary anemia and physical asthenia; we operated the patient procedeeing a polypectomy by a duodenotomy.

Port-site metastasis after laparoscopic surgery for colorectal cancer--still a real concern? Case report and review of the literature.

BACKGROUND: The recently published long-term oncological results of the large multicentric randomized prospective trials, such as COST, COLOR, and UK MRC CLASICC, have diminished once more the initial skepticism from the mid '90s, regarding the safety of laparoscopic approach for colorectal cancer surgery. The actual incidence of port-site metastases (PMSs) in the laparoscopic surgery for colorectal cancer is just arround 1%, being statistically simmilar to the wound metastases after open colorectal surgery. We followed up a series of 122 laparoscopic-assisted resections for colorectal adenocarcinoma, 49 for rectal cancer and 73 for colon cancer. The operations were performed at the Center of Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania, between 1st January 2002 and 31st december 2008. There was only one case of PMS (0.81%). CASE-REPORT: A 83-year old man developed a recurrent parietal tumor on the site of extraction minilaparotomy, 4 months after laparoscopic-assisted right hemicolectomy for a Dukes C, poorly differentiated (G3) adenocarcinoma of the cecum. DISCUSSIONS: We have reviewed the scientific relevant literature regarding the incidence and multi-factor etiology of PMSs in the laparoscopic surgery for colorectal cancer as well as the methods suggested for prevention of parietal tumour dissemination to the trocar or wound sites. CONCLUSION: PMSs consecutive to laparoscopic surgery for colorectal cancer are no longer a big concern enough to contraindicate this beneficial surgery for oncological reasons. However, PMSs continue to represent a reality which must be taken into consideration by any laparoscopic surgeon. There are different prevention measures that should be applied for reducing the occurence of this possible complication.

[Gastrointestinal stromal tumor with primary hepatic unique location--clinical case]. / Tumora gastrointestinala stromala cu localizare hepatica primara unica--caz clinic.

The gastrointestinal stromal tumors are mesenchymal tumors whose primary extradigestive location is very rare (less than 10% primary liver localization). We present a clinical case of primary hepatic location of GIST in a 28 year-old patient. The discovery of this tumor is a chance, the patient presenting for non-specific dyspeptic syndrome and epigastralgia. During the presentation an abdominal ultrasound is performed which identifies an whell-delineated hepatic mass - 5/4 cm. Clinical and paraclinical investigations (CT, EDS, EDI, examination of the intestinal lumen with the videocapsula), confirm the diagnosis of unique hepatic mass of segments III-IV. The diagnosis is confirmed intraoperatory and we perform an atypical liver resection of segments III-IV (with 1 cm safety-margin). The histopatologic exam: GIST.

[Comparative study of three series of neuro-cutaneous flaps used for coverage of leg defects]. / Studiu comparativ a trei serii de lambouri neuro-cutanate folosite in acoperirea defectelor la gamba.

The purpose of the trial was to compare three groups of neurocutaneous flaps used to cover defects in the calf, in terms of preoperative characteristics and postoperative results. The main objective was to evaluate the effectiveness of surgical method by testing the hypothesis: neurocutaneous flaps can be applied with clinical results comparable to other surgical methods. The results were presented in the text, through graphic figures and tables. Statistical comparisons were performed according to the results obtained from three series of neurocutaneous flaps in terms of demographic characteristics and those describing postoperative results. The results obtained in the three types of flaps were compared with studies published by other authors, confirming the working hypothesis. The most important results are: the neurocutaneous sural flap is a distal pedicled flap with increased vascular resistance; age and co-morbidities may influence the degree of immediate complications but not the final success rate; the covered defect surface (p = 0.035) is higher for the sural and saphenous flap; the number of days of hospitalization is significantly lower than for microsurgical transfer flaps (p = 0.022). The frequency of complications and reintervention rates were similar (p = 0.022). The study concludes that the sural neurocutaneous flap can be used to cover defects of up to 200 cm2 in the calf with similar results to those of microsurgical transfer flaps.

[Laparoscopic choledochoscopy]. / Coledocoscopia laparoscopica.

AIM: Of this study was to evaluate the treatment of common bile duct stones (CBDS) by laparoscopic choledochoscopy. MATERIAL AND METHOD: Between 1997-2002, 9 patients (with age between 42-75 years) were treated laparoscopic for CBDS: 8 cases with choledocholithiasis; 1 case with pancreatic neoplasm. Laparoscopic choledochoscopy was performed in 7 cases (84.4%). We used the choledochoscope Pentax of 5 mm diameter and with work canal. RESULTS: We performed the CBD exploration with: transcystic approach-1 case; choledochotomy-6 cases. The CBD diameter was between 1.2-1.5 cm. The bile duct stones diameter were between 0.5-1.5 cm. We performed with successfully the laparoscopic choledochoscopy exploration and extraction of CBD stones to all patients. External biliary drainage (transcystic duct and with Kehr-tube) were done systematically. The major complication (choleperitoneum) occurred in 2 cases (28.5%). The occurrence of residual ductal stones was 0. CONCLUSION: The laparoscopic treatment of choledocholithiasis is feasible, safe and efficient.

[Consideration regarding 20 antireflux laparoscopic operations for hiatal hernia]. / Consideratii în legatura cu 20 operatii antireflux efectuate pe cale laparoscopica pentru hernia hiatala.

AIM: To evaluate the clinical, therapeutical and evolutive aspects of the patients with hiatal hernia with laparoscopical approach. MATERIALS AND METHODS: Retrospective analysis of 20 patients diagnosed with hiatal hernia and operated, laparoscopical, between 13.01.1999-10.04.2002. RESULTS: At 18 cases (90%), were sliding hiatal hernia and at 2 cases (10%), were paraesophageal hiatal hernia. There were performed laparoscopical: 1 (5%) Dor anterior hemi-fundoplication, 4 (20%) Rosetti fundoplication, 3 (15%) Toupet posterior hemi-fundoplication and 11 (55%) Nissen fundoplication. For the dissection, the ultrasound scissors (Ultra-Shears) was used and for the suture of the both diaphragmatic crus and the wrap, the Endo-Stitch. There were reported 1 (5%) optional conversion and 3 cases (15%) with bleeding solved by clipping and hemostatic suture. No postoperative complications, deaths intra and postoperative were reported. The average duration of the intervention decreased in time, due to the experience, from 180 to 60 minutes, but in accordance with the complexity of the procedure (Nissen-Toupet-Dor). At 2 (10%) cases with Nissen fundoplication was reported a transitory dysphagia, which was remitted between 1-2 months. We noticed a decreasing of the duration of hospitalisation for the antireflux laparoscopical interventions, compared with the classic methodes. CONCLUSIONS: There is a tendency of the laparoscopical approach of hiatal hernia to come the standard in the GERD, due to his minimal invasive character, significantly reducing costs and good postoperative results.

[Intraoperative diagnosis of common biliary duct using laparoscopic ultrasonography]. / Diagnosticul intraoperator al litiazei de cale biliara principala prin ecografie laparoscopica.

THE AIM: Of the study is to show the advantages and limits of laparoscopic echography in exploration and diagnosis of common biliary duct lithiasis, as it is evidenciated in the experience of our surgical department. MATERIAL AND METHODS: Between 31.03.1997-31.12.2002 we have made 878 laparoscopic interventions to patients with hepatho-biliary pathology. We made a prospective study and performed 116 laparoscopic ultrasonography examinations for exploration of the liver and bile ducts. We used an Aloka SSD 2000 device with a linear laparoscopic flexible transductor. RESULTS: We obtained a very good visualization in 97 cases (83.6%) and medium visualization in 19 cases (16.4%). The medium time of the examination was 10 minutes (variations between 5-20 minutes). We discovered pathological modifications in principal bile duct and cystic using color Doppler examination in acute and chronic inflammatory lesions with important anatomical modifications. CONCLUSIONS: 1. laparoscopic ultrasonography it is an ideal technique in common bile duct lithiasis diagnosis, with 90-98% precision. 2. intraoperative ultrasonography does not need preliminary dissection of cystic and offers the possibility of exploration of the liver and pancreas. 3. it needs a learning curve and collaboration between surgeon and ultrasonography specialist.

[Cortico-suprarenal carcinoma]. / Carcinom de glanda corticosuprarenala.

The authors show the case of a 69 years old male with a large corticosuprarenalian tumor that was detected on an random abdominal echographic examination. The patient was operated in the General Surgery Department. of Prof. Agrippa Ionescu Hospital, Bucharest. We performed ablation of the large left suprarenalian gland malign tumor with left nephrectomy, splenectomy and partial pancreatectomy. The hystopathological examination reveals a diffuse corticosuprenalian carcinoma. The case is interesting because of low incidence of this kind of malign tumor and also of the unusual tumor evolution in a long time up to its large size (12 cm in diameter).

[Diagnosis of diaphragmatic hernia]. / Diagnosticul herniilor diafragmatice.

Diaphragmatic hernias (congenital and traumatic) belongs to thoracoabdominal surgery which is a borderline chapter. Considering frequency, they are on the second place in the diaphragmatic pathology, after hiatal hernias. The author presents the criterias of the clinical examination, based on the bibliographic datas: also by presents the imagistic investigations used for identification of the diaphragmatic hernias, excepting the oesophageal hiatus hernias. There are some particular features appearing in the diagnostical algorithm, too.

[Serous cysts of the spleen treated by laparoscopic surgery]. / Chiste seroase splenice rezolvate pe cale laparoscopica.

The authors present two case of a 25 years and 32 years old male patients with serous cysts of spleen that were detected on an random abdominal ultrasonography. Abdominal pain in the left hypocondrium was only symptom of this patients. The patients was operated by laparoscopic method, with Ultra-Shears and intraoperative ultrasonography examination. This kind of techniques give us the opportunity to performed the ablation of the cysts with preservation of the spleen with fast full recovery.

[Gastric stromal tumor treated by laparoscopic surgery]. / Tumora stromala gastrica rezolvata pe cale laparoscopica.

UNLABELLED: The authors describe a 59 years old female patient, with a gastrointestinal stromal tumor located on the posterior wall of the gastric funds, who was treated successfully by laparoscopic wedge resection (with clear resection margins), through an anteriorly placed gastrotomy, thus allowing an endoscopic linear cutter Endo GIA, to excise the tumor with a cuff of normal gastric tissue. The anterior gastrotomy was performed with Ultra-Shears. Delivery of the tumor through the gastrotomy is essential for success. The operative time was 110 minutes. The tumor was diagnosed as a gastrointestinal stromal submucosal tumor (of low-grade malignancy) and immunohistochemicaly, this tumor was positive for CD 34. CONCLUSION: Posterior gastric tumor can be removed using laparoscopic surgery.

[Mechanical suture in colorectal surgery]. / Sutura mecanica în chirurgia colorectala.

THE OBJECT: Of this work was the study of using, as well as the utility of the mechanical sutures in colorectal surgery; because of the special caution needed to be taken for any colonic or rectal suture, more than any other digestive segment. The frequency of the postoperative fistulas after the suture and anastomosis is higher at this level and so it increases the period and costs of the hospitalization. MATERIAL AND METHOD: We studied the possibilities of performing and evolution of 64 mechanical sutures for 19 patients, with colorectal pathology, hospitalized in our department from july 1999 to december 2000. RESULTS: We performed 64 mechanical sutures, as followed: 47 in open surgery and 17 in laparoscopic. From all these, 56 was bowel sutures, 8 of them were vascular (in laparoscopic, for cutting the most important vascular pedicles). We did 18 anastomosis: 15 in open and 3 in laparoscopic surgery. It was 2 postoperative fistulas from all 56 intestinal sutures (3.57%). We haven't any intra or postoperative bleeding from the vascular anastomosis. It was 3 intraoperative bleeding from the intestinal anastomosis, and only 1 case of postoperative bleeding (5.26% of the cases: 1.56% of all mechanical sutures). In only one case, the mechanical suture couldn't be initially done, but it succeeded after the removing of the segment of the bowel involved. CONCLUSIONS: Mechanical sutures offers a high level of safety to the colorectal anastomosis. It provides a very good vascularization to the anastomosis and decreases the time needed for performing the suture or anastomosis, versus manual sature. Also, for the patients with rectal ampular neoplasm, it creates the possibility of anal sphincter preservation by making a low colorectal anastomoses--which is difficult by manual suture.

[Intraoperative ultrasonography, dissection with ultra-shears and trans-cystic choledochoscopy during laparoscopic approach in obstructive lithiasis icterus case]. / Ecografie intraoperatorie, disectie cu foarfeca cu ultrasunete si coledocoscopie transcistica într-un caz de icter mecanic litiazic rezolvat pe cale laparoscopica.

The authors present the case of a 48 years old male with lithiasis obstructive icterus who was operated by laparoscopic transcystic approach with choledochoscopy. This minimally invasive technique was very spectacular trough the using of laparoscopic ultrasonography, dissection with Ultra-Shears device and transcystic choledochoscopy. Careful watching of abdominal laparoscopic view and transcystic choledochoscopic view is the particularity of laparoscopic transcystic management of choledocholithiasis. This metod don't let us to explore the biliary tract before the junction between common bile duct and cystic duct.