Laparoscopic management of heterotopic pregnancy--a rare cause of acute abdomen in women.

Heterotopic pregnancy is a rare condition of coexisting intrauterine and extrauterine pregnancy and can present as an acute abdomen. The management can be challenging as the diagnosis is difficult to establish preoperatively. We report a case of a 31-year-old female presenting with acute abdominal pain and a mass in the right iliac fossa at 22 weeks of gestation. The patient was provisionally diagnosed as having an appendicular mass and was managed conservatively, however a diagnostic laparoscopy revealed the presence of an ectopic tubal pregnancy. This was successfully treated with laparoscopic right salpingectomy. A brief review of the management of heterotopic pregnancy is presented with an emphasis over laparoscopic management. The potential advantages and risks of laparoscopic approach in this situation are discussed. Laparoscopic management of these cases is possible, however, requires the availability of an experienced surgeon, trained staff, and laparoscopic equipment. Low-pressure pneumoperitoneum and use of direct vision ports for access is fundamental in achieving favorable maternal and fetal outcomes.

Ileocolic Intussusception - A rare cause of acute intestinal obstruction in adults; Case report and literature review.

Colonic Intussusception although common in children, is a rare cause of acute intestinal obstruction in adults. The etiology, clinical presentation and management of this condition is different in adults as compared to children. Pre-operative diagnosis is usually difficult due to the non specific and intermittent nature of the symptoms. CT scan can be a helpful adjunct in establishing the diagnosis. We present a case report of adult ileocolic intussusception with classical radiological signs and operative findings. A brief literature review is also presented with emphasis on the controversy of reduction of the intussusception before resection.

Laparoscopic versus open appendectomy: the risk of postoperative infectious complications.

BACKGROUND: Despite the reported advantages of laparoscopic appendectomy (LA), ongoing debate exists about a possible increase in postoperative infectious complication rates especially intraabdominal infections and wound infection, unless wound protection is utilized. METHODS: All consecutive appendectomies (open and laparoscopic) performed over 4 months were included in this prospective study. Demographic details, operative time, time to conversion, infective postoperative complications, and delay in discharge were recorded. The patients were divided into 2 groups, laparoscopic (LA) and open appendectomy (OA). RESULTS: A total of 134 appendectomies were performed, 80 in the LA group and 54 in the OA group. Twenty-six (19.4%) appendices were perforated at the time of operation. The median patient age was 24 years (range, 7 to 63). Patients included 71 females and 63 males. Operating time in the LA group was longer with a median duration of 51.3 minutes (range, 35 to 100) compared with 40.6 minutes (range, 30 to 95) in the OA group. An extraction bag was used in 59/71 (83%) LA patients. Wound infection was recorded in 6 patients (5/54 in OA and 1/80 in LA). The site of wound infection was the port of specimen extraction in the laparoscopic group, and an extraction bag was not used. Wound infection delayed hospital discharge by an average of 2 days. Intraabdominal abscess formation complicated the outcome in 2 patients (1 in the LA group and 1 in the OA group). CONCLUSION: Wound infection is less common in LA than in OA, and an extraction bag is recommended. Intraabdominal infection rates do not appear to be increased, though the numbers in this study are relatively small. The longer operating time is minimal given the better results, and LA is the optimal approach to the diagnosis and management of acute appendicitis.

Four percent of patients undergoing colorectal cancer surgery may have synchronous appendiceal neoplasia.

PURPOSE: An individual with colorectal cancer has a 3 percent risk of synchronous colonic neoplasia and further 2 to 3 percent risk of metachronous cancer, a risk that has prompted colonic surveillance. The appendix has a similar mucosal pattern to the colon and it has been hypothesized that appendicular adenocarcinoma may account for 1 percent of all colorectal malignancies. A special interest of the senior author in appendiceal and rectal cancer has prompted routine removal of the appendix in all cases undergoing surgery for colorectal cancer. METHODS: Consecutive patients undergoing left colectomy or anterior resection for colorectal cancer had coincidental appendectomy with the specimen pathologically analyzed. A retrospective review of the case notes and histopathology was performed. Data also were collected for patients who had right hemicolectomy for colonic carcinoma. RESULTS: In total, 169 patients under the care of a single surgeon had colorectal cancer resection between April 2002 and April 2005: 63 patients had right hemicolectomy, 29 had left hemicolectomy, and 77 had rectal cancer resection. Seven of 169 appendices had abnormalities: 3 mucinous cystadenomas, 2 cystadenocarcinomas, 1 carcinoid tumor, and 1 villous adenoma. CONCLUSIONS: Patients having colorectal cancer resection for adenocarcinoma should have appendicectomy performed. Synchronous pathology was found in 4.1 percent in this series. Metachronous neoplasia is a risk in the retained appendix in patients with colorectal cancer. Routine postoperative surveillance cannot assess the appendiceal mucosa, so there is little justification for not taking the opportunity to eliminate the possibility of future appendicitis or neoplasia.

Frequency and risk factor of abdominal wound dehiscence.

OBJECTIVE: To find out the frequency of abdominal wound dehiscence (AWD) in a tertiary care hospital and the assessment of associated risk factors. DESIGN: a cross sectional analytical study. PLACE AND DURATION OF STUDY: This study was carried out at Nishter Hospital Multan between May 1998 to May 2000. SUBJECTS AND METHODS: This study was carried out on 406 patients who underwent laparotomy for intra peritoneal procedure and complied with inclusion criteria. Demographic features were recorded and any complications documented. RESULTS: Out of a total of 406 patients, 32 showed wound dehiscence giving an over all frequency of 7.8%. The male to female ratio was 2.8:1. The frequency was greater in males than in females. Majority patients suffered from an underlying malignancy. Malignant intestinal obstruction was the leading cause of wound dehiscence. Forty three patients had hypo-albuminemia(serum albumin <35 gm/l) and 09 of them had AWD. Emergency surgery showed a higher frequency of AWD(12.5%), as compared to elective surgery (18/143 and 14/263 respectively ). Wound infection was a major contributor to AWD as out of 406, 76 patients developed infection and then 21 manifested AWD. older age was also associated with greater frequency. The overall mortality of AWD in this study was 28.1%. CONCLUSION: AWD still continues to be major post operative complication, with a high morbidity and mortality. The significant risk factors in this study were age more than 55 years, male gender, underlying malignancy, wound infection, jaundice, use of steroids, emergency surgery, uraemia and technique of closure.