Towards cost saving in surgery without compromising safety: stapleless laparoscopic splenectomy in a developing country-a prospective cohort study.

BACKGROUND: Minimally invasive surgery has been steadily growing in popularity. Control of splenic hilar vessels is the most delicate step during laparoscopic splenectomy (LS). In the earlier eras of LS, hilar vessels were controlled using clips and/or ligation. Laparoscopic staples were later introduced and have arguably led to an increase in popularity of LS. They do not abolish potential complications of splenectomy and theoretically represent an added operative cost.In this study, we aimed to assess the safety and efficacy of stapleless LS (using knots, haemostatic devices and clips) compared with the now more conventional stapled LS. METHODS: A pilot randomised prospective study was conducted in a university hospital between September 2018 and April 2020. It included 40 patients randomly assigned to two equal groups: (1) 20 patients: stapleless LS and (2) 20 patients: LS using laparoscopic staples.We compared operative time, intra and postoperative complications and postoperative recovery. RESULTS: There was no statistically significant difference between both groups across all comparative outcomes. CONCLUSION: Both techniques are comparable in terms of safety and operative time. In terms of cost efficiency, we recommend more comprehensive analyses of hospital costs.

Spontaneous trans-anal evisceration of small bowel: a case report.

Trans-anal evisceration of small bowel is a rare surgical presentation. The first case ever reported was in 1827. The exact mechanism of how this develops remains poorly understood. A 70-year-old lady presented with multiple small bowel loops eviscerated through the anus. Abdominal exploration was done. The bowel was carefully reduced. There was a longitudinal defect on the anterior wall of the rectum at the recto-sigmoid junction and a large mesenteric defect and thrombosed mesenteric vessels compromising blood supply to part of the bowel. Resection of 50 cm of ileum, jejunostomy and a mucous fistula were performed. Several preexisting pathologies such as rectal prolapse can result in thinning out of the wall of the rectum. That combined with increased intra-abdominal pressure can explain trans-anal evisceration of the bowel. This condition is managed by surgical intervention. The operation will depend on the extent of viability, contamination and patient's general condition.

Abdominal Cocoon or Encapsulating Peritoneal Sclerosis: A Rare Cause of Small Bowel Obstruction.

Encapsulating peritoneal sclerosis (EPS), also known as abdominal cocoon syndrome (AC) or sclerosing encapsulating peritonitis (SEP), is an uncommon condition typically presenting with features of bowel obstruction. We present the case of a 41-year-old male patient who presented to the accident and emergency department with a 7-day history of abdominal pain. Contrast CT of the abdomen and pelvis was ordered and was suggestive of small bowel obstruction involving most of the small bowel with no apparent transition point. Laparotomy showed a tough whitish fibrous membrane encasing the entire length of the small bowel. Advances in CT have made diagnosis possible before a decision on surgical intervention is made. LEARNING POINTS: Despite being a rare cause of bowel obstruction, based on the clinical presentation and CT findings, abdominal cocoon syndrome should be included in the differential diagnosis.CT of the abdomen is the investigation of choice for most cases of bowel obstruction and can be very helpful in reaching a diagnosis before operative management is undertaken.Laparotomy is the usual choice for management, but laparoscopy can be considered either to establish the diagnosis or to deal with the abdominal cocoon based on the surgeon's clinical judgement and experience.