Successful term pregnancies after laparoscopic excision of poorly differentiated Sertoli-Leydig cell tumor of the ovary.

Ovarian Sertoli-Leydig cell tumors are rare sex cord-stromal tumors, accounting for less than 1% of ovarian tumors. Majority of these tumors are benign and unilateral, only 3-5% are bilateral. These patients present with clinical features of virilization due to excessive secretion of testosterone from the tumor, however 50% may have no endocrine symptoms. We report a case of poorly differentiated Sertoli-Leydig cell tumour in a woman diagnosed during routine investigation of infertility. She had two spontaneous successful pregnancies after tumor excision laparoscopically.

Laparoscopic Splenectomy Using LigaSure.

BACKGROUND: Laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases. Bleeding is the main complication and cause for conversion. We present our experience with the LigaSure and discuss its advantage as a vessel sealing system in achieving safe vascular control. METHOD: Over a 3-year period, we performed 12 consecutive LS using LigaSure at a single center. A literature review of all the patients who had undergone laparoscopic splenectomy with of the LigaSure to achieve vascular control at the hilum was carried out, assessing its advantages and outcome. RESULTS: Twelve LS were performed. Eleven of these patients had ITP, and one patient had sickle cell disease. The mean blood loss was 70mL (range, 50 to 460), and operating time was 126 minutes (range, 110 to 240). Two postoperative complications occurred: portal vein thrombosis in one case and subphrenic collection in the other. The literature review revealed 8 studies with 231 cases in which the LigaSure was used to perform laparoscopic splenectomy. A significant reduction in operating time (average 102 minutes) and intraabdominal blood loss (66mL) was observed with the LigaSure compared with endostaplers. CONCLUSION: The use of LigaSure and the semilateral position results in a gain of time and safety in addition to low intraoperative bleeding, need for transfusion, minimal complications and a low conversion rate.

Splenectomy for haematological disorders: a single center study in 150 patients from Oman.

BACKGROUND: Haematological disorders, in particular sickle cell disease (SCD) and thalassaemia, are relatively common in Oman. We report our experience of splenectomy for haematological disorders and review the literature on splenectomy role in their management. OBJECTIVES: To review our experience in the management of 150 patients with haematological disorders undergoing splenectomy with emphasis on indications and outcome. To compare our experience with those reported from outside this region. METHODS: The records of 150 patients who underwent splenectomy over a thirteen year period were reviewed retrospectively, analyzing the age and sex of the patients, indication for splenectomy, operative procedures, complications, peri-operative management and outcome. RESULTS: Of the 150 patients, 96 (64%) had SCD and 34 (22.6%) had beta-thalassaemia; the rest comprised patients with refractory idiopathic thrombocytopenic purpura (ITP) n=12, hereditary spherocytosis (HS) n=6, and auto-immune haemolytic anaemia (AHA) n=2. In SCD patients, the main indications for splenectomy were recurrent splenic sequestration (60.4%) and hypersplenism (36.4%), whereas in thalassaemic patients it was increased requirement of packed red blood cells (PRBC) transfusion (mean 310 ml, range 242-372 of PRBC/kg/year). All patients received prophylactic antibiotics and vaccination against pneumococcal infection and when the vaccine was available for Haemophilus influenzae. PRBC and platelet concentrates as well as intravenous fluids were infused preoperatively as per protocol. Concomitant procedures at laparotomy included liver biopsy (14.6%) and cholecystectomy (8.6%). The postoperative morbidity was low (8.6%) and there was no mortality. All patients were maintained on long term penicillin and proguanil, and the mean follow-up was 4.6 years. In SCD patients splenectomy eliminated the risks of life threatening acute splenic sequestration and improved significantly the blood counts of the hypersplenic cases, while in thalassaemic patients it reduced significantly the mean transfusion requirement by 100ml PRBC/kg/year (p<0.0001). Of the patients with refractory ITP, two thirds had a good response to splenectomy (p<0.0001). All HS and AHA patients benefited from splenectomy. CONCLUSION: The predominant indications for splenectomy were recurrent acute splenic sequestration and hypersplenism in SCD patients, and increased transfusion demand in the thalassaemics. Overall, splenectomy proved beneficial in eliminating the risk of splenic sequestration in SCD patients, in improving the blood counts in SCD with hypersplenism and in reducing transfusion requirement in thalassaemic patients, while in ITP group two thirds of the patients benefited.

Insulinoma: a rare cause of a common metabolic disorder - hypoglycaemia.

We describe the first patient diagnosed with an insulinoma in Oman and successfully managed with a distal laparoscopic pancreatectomy. The importance of obtaining a good history from the patient and/or his family is stressed. All patients with loss of consciousness must have a Reflow check carried out and, if hypoglycaemic, this should be documented in the laboratory and a simultaneous serum sample stored for measurement of insulin, C-peptide proinsulin and sulphonylurea levels, if subsequently indicated. If magnetic resonance imaging fails to locate the tumour, endoscopic ultrasound of the pancreas, or indium 111 labelled octreotide scanning is indicated if the patient's hypoglycaemia has previously responded to treatment with octreotide.

Surgery in Oman.

During the past 3 decades, Oman (a sultanate), a country with deep-rooted history, culture, and traditions, has undergone a remarkable transformation and modernization in all fields, including education and health care. It has progressively established a nationwide network of modern health services that are accessible even at the village level and have ranked Oman with the developed world. More than 300 surgeons provide a full range of surgical services for a population of 2.5 million. Medical education is firmly established, and accredited surgical residency training has assumed increasing importance during the past decade. Given the sustained growth and dynamic planning, the surgical services will continue to develop, with Omani surgeons playing an increasing role in the future.