Type VI Choledochal Cyst-An Unusual Presentation of Jaundice.

Choledochal cysts involving the cystic duct are extremely rare, and are usually associated with cystic dilatations of the extrahepatic biliary tract. We describe a patient who presented with jaundice and was found to have a dilatation of the common bile duct on computed tomographic imaging, consistent with a choledochal cyst. He underwent a laparoscopic-converted-to-open cholecystectomy with excision of the choledochal cyst which was found to involve the cystic duct. Choledochal cysts involving the cystic duct are notably missing from the Todani classification. Although exceedingly rare, new cases of these types of cysts are being reported, in part due to advancement of diagnostic imaging modalities. We discuss the current classification scheme for choledochal cysts and we propose an expansion of this scheme.

Experience with seven cases of massive splenomegaly.

BACKGROUND: Laparoscopic excision of extremely large spleens has been variously reported, but the usual consensus in the literature is that any patient with a spleen anything over 3000 g is simply not a proper candidate for laparoscopy. This report details our experience with 7 patients (out of 95 operated on) with spleens ranging in size up to 4800 g. METHODS: Our operative procedure involved 3 or 4 trocars placed along a virtually semicircular line centered over the splenic hilum. Splenic attachments were excised with the ultrasonic dissector, and the hilum divided with a stapler. Due to the size of the spleens, Pfannenstiel's incisions were utilized for hand-port placement in the extraction of the specimen. RESULTS: Surgery was successful in all 7 cases, and required no conversion to an open procedure. The average splenic weight was 3450 g (range, 3000-4800 g). Mean operative time was 168 minutes (range, 127-250 minutes). CONCLUSION: Because of improved instrumentation (i.e., laparoscopic stapler and ultrasonic dissector) and refinement of technique, spleens very much larger than what was once considered practicable can now be excised laparoscopically with similarly low morbidity as compared with open splenectomy.

Mesh infection in the era of laparoscopy.

BACKGROUND: The incidence of mesh infection during open hernia repair has been reported to be as high as 3%. With the introduction of laparoscopy, the rate of infection is still a matter of debate. METHODS: All 1182 laparoscopic inguinal hernia repairs performed at our institution from September 1991 to June 2002 were retrospectively reviewed to identify both mesh and wound infections. RESULTS: There were two mesh infections (0.17%) during that period, and one wound infection. CONCLUSION: The incidence of mesh infection in laparoscopic repair is considerably lower than in the open procedure. The two main reasons for this are the introduction of mesh through trocars to avoid skin contact, and the mesh is placed far from the trocar incisions, again avoiding contamination. The rate of wound infection is not related to that of mesh infection, and depends mainly on aseptic prepping techniques prior to surgery.