Gallstone impacted in the rectosigmoid junction causing a biliary ileus and a sigmoid perforation.

A gallstone ileus is an unusual form of bowel obstruction. Colonic gallstone ileus is rare, difficult to diagnose, and still has a high mortality rate. We present a case of biliary ileus caused by an impacted gallstone, causing necrosis and perforation of the rectosigmoid junction. A Hartmann's procedure was performed to treat the perforation and the obstruction. Cholecystectomy and closure of the cholecysto-colonic fistula were delayed until restoration of the intestinal continuity.

An unusual case of blunt abdominal trauma: A bleeding and ruptured gall-bladder managed by laparoscopy.

An isolated gall-bladder injury after blunt abdominal trauma is rare. Intraluminal bleeding with a perforation and an intra-abdominal haemorrhage is even rarer. Early diagnosis is difficult, even with a CT-scan or an US-scan available. Clinical suspicion, serial clinical examination and repeated imaging, can prevent mortality and morbidity. We present a case where laparoscopy was used to diagnose and treat an isolated gall-bladder lesion after blunt abdominal trauma.

Laparoscopic liver resection of benign liver tumors.

OBJECTIVE: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting. BACKGROUND: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors. METHODS: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. RESULTS: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD. CONCLUSIONS: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Pitfalls in laparoscopic cholecystectomy.

On the basis of literature and of 475 laparoscopic cholecystectomies of the authors, some pitfalls are reviewed. The circumstances, the mechanism and the prevention of injuries were detailed together with the connected problem of postoperative bile leakage. Among the cholangiographic pitfalls the importance of detection of congenital and acquired anomalies of the biliary tree by means of preoperative ERCP or intraoperative trans-cystic cholangiograms was emphasized. A particular study was made of 3 pictures: Mirizzi syndrome; stone impaction in Vater's papilla; no retrograde flow of the common hepatic duct on intraoperative cholangiograms. Biliodigestive fistulas were briefly commented. The problems with cystic duct stones, particularly the treatment of stones in a long, low inserted cystic duct with retroduodenal course and the closing of thick-walled or wide cystic stumps, were explained. In patients with intraoperative residual common bile duct stones and with failed preoperative catheterization of the papilla, the authors advocate their double approach technique. This combined intraoperative laparoscopic and postoperative endoscopic procedure is carried out via the same transcystic polythene catheters as used for cholangiography and external biliary drainage of the common bile duct.

Hirschsprung's disease in adults: the Duhamel procedure.

Hirschprung's disease is a rare condition in the adult. We present three patients with Hirschsprung's disease who successfully underwent the modified Duhamel procedure. The diagnosis was suspected on the basis of the typical medical history of lifelong constipation. The diagnosis was confirmed by anorectal manometric studies and/or full thickness rectal biopsy. The relief of the marked preoperative abdominal distention was complete and the bowel movements were active and smooth. Two out of three had perfect faecal control and continence. The Duhamel-Martin procedure seems a safe and reliable technique in the treatment of Hirschsprung's disease.

Paraoesophageal hernia with acute intrathoracic volvulus of the stomach after laparoscopic Nissen fundoplication.

In experienced hands, the value of the laparoscopic Nissen fundoplication as antireflux correction is established. The case report concerns a woman who underwent an emergency laparotomy for acute intrathoracic stomach volvulus with incarceration, one year after a laparoscopic Nissen fundoplication was carried out without closure of the diaphragmatic hiatus. In literature acute postoperative paraoesophageal hernia with intrathoracic migration of the stomach as an early and late complication of the laparoscopic fundoplication has already been reported. The authors advocate the closure of the diaphragmatic crura as a routine manoeuvre during the laparoscopic fundoplication.