Laparoscopic cholecystectomy and appendectomy in situs inversus totalis.

Situs inversus totalis is an uncommon anatomic anomaly that complicates diagnosis and management of acute abdominal pain. Expedient diagnosis of common intraperitoneal disease processes such as biliary colic, acute appendicitis and diverticulitis is often delayed as a result of seemingly incongruous physical findings. We present the case of a young woman with prior emergency room visits for complaints of a vague left upper quadrant abdominal pain. An ultrasound performed on her third presentation revealed visceral situs inversus with cholelithiasis and dilated intra- and extrahepatic biliary ducts. Standard laparoscopic cholecystectomy and cholangiography with a mirror-image surgical approach was performed successfully and without complication.

Intraoperative monitoring of recurrent laryngeal nerve function.

Intraoperative recurrent laryngeal nerve identification is sometimes difficult in reoperative cervical dissection or operation for inflammatory thyroid disorders. Three modalities have been described to intraoperatively assess nerve function: vocal cord visualization with fiberoptic bronchoscopy or direct laryngoscopy, electromyelographic surveillance of arytenoid muscle function, and cord function assessment with an electromyelogram-electrode endotracheal tube. Our study focused on patients requiring cervical dissection for thyroid or parathyroid disease in which intraoperative recurrent laryngeal nerve function was monitored by nerve stimulation with a concentric bipolar probe. Impulses were tracked via a specialized electrode-bearing endotracheal tube with signal transduction to a recording monitor. No operative nerve injuries occurred in the patients of our study group. This surveillance technique's several advantages include use of standard intubation techniques with no increase in operative time, nerve stimulation tracings that are quantifiable and reproducible with production of a permanent record, and less subjectivity due to observer variability. We believe these factors make the electromyelogram-electrode endotracheal tube approach to intraoperative recurrent laryngeal nerve assessment the optimal technique.

Laparoendoscopic diagnosis of eosinophilic enteritis.

As the popularity of laparoscopic cholecystectomy continues to grow, evaluation of patients with documented cholelithiasis and concomitant vague abdominal complaints becomes less rigorous. We present the case of a patient with chronic cholecystitis documented by history and ultrasonography, incidentally noted on laboratory examination to have peripheral blood eosinophilia. At the time of laparoscopy, an inflamed segment of jejunum was discovered. Limited laparotomy and wedge biopsy revealed active eosinophilic enteritis.