Adhesive bowel obstruction? Not always.

A 58-year-old man presented acutely with features of post-surgical adhesive small bowel obstruction. Following an unsuccessful trial of conservative management, computed tomography (CT) of the abdomen was performed. This revealed a mass in the ileocaecal region, for which he underwent a subsequent right hemicolectomy. Histology revealed diffuse B-cell Non-Hodgkin's lymphoma of the terminal ileum. Confounding obstructive lesion of the intestine in patients with a history of previous laparotomy is extremely uncommon. Early high resolution imaging may predict diagnosis and consolidate clinical management plans.

A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK.

BACKGROUND: Recent management guidelines and randomised clinical trials have provided evidence-based guidance to the management of acute biliary pancreatitis and acute cholecystitis. METHODS: A questionnaire was sent to the 1086 members of the Association of Surgeons of Great Britain and Ireland. There were 583 responders (54%). RESULTS: A policy of cholecystectomy during the index admission or within 4 weeks in fit patients recovering from mild acute biliary pancreatitis was adopted by 58% of surgeons, and was significantly associated with an upper gastrointestinal and hepato-pancreato-biliary subspecialty interest and a volume of more than 50 cholecystectomies per annum (OR, 0.43; 95% CI, 0.26-0.72; P = 0.001: and OR, 0.46; 95% CI, 0.29-0.74; P = 0.001, respectively). A policy of urgent cholecystectomy for acute cholecystitis was adopted by 20% of surgeons, and was significantly associated with an upper gastrointestinal/hepato-pancreato-biliary subspecialty interest and the 'routine' adoption of laparoscopic approach to cholecystectomy (OR, 0.34; 95% CI, 0.19-0.60; P < 0.001: and OR, 0.51; 95% CI, 0.3-0.86; P = 0.01, respectively). CONCLUSIONS: The management of cholelithiasis in patients with acute biliary pancreatitis in the UK remains suboptimal. Moreover, only a minority of surgeons offer patients presenting with acute cholecystitis the benefits of early laparoscopic cholecystectomy. The management of acute biliary disease may be improved if these cases were concentrated in the hands of surgeons with upper gastrointestinal/hepato-pancreato-biliary interest and those who perform laparoscopic cholecystectomy regularly.

"Semi-open" blunt primary access to the abdominal cavity during laparoscopic surgery: a new technique.

BACKGROUND: Despite major technologic advances in laparoscopic surgery, the creation of the pneumoperitoneum remains a critical step and is associated with a recognized incidence of complications. The aim of this study was to evaluate the safety and feasibility of a new "semi-open" blunt technique for primary cannulation of the abdominal cavity in patients undergoing laparoscopic surgery. METHODS: Between October 2000 and November 2001, 300 patients underwent laparoscopic surgery under the care of one surgeon. Surgery was elective in 158 patients and urgent/emergent in 142 patients. The semi-open blunt technique for primary cannulation of the peritoneal cavity was applied in 241 (80%) of the patients and was periumbilical in most cases. A closed blunt technique was applied in 48 (16%) of the patients, and the Veress needle was used in 11 (4%) of the patients. RESULTS: The semi-open blunt technique for primary cannulation of the abdominal cavity successfully achieved access in all patients in whom it was attempted. Minor live injuries occurred in two patients (one with the semi-open method and one with the Veress needle). No port site incisional hernias were encountered during a median follow-up of 6 months. CONCLUSIONS: The semi-open blunt technique of primary cannulation of the peritoneal cavity achieves rapid, safe, and successful access to the abdomen for laparoscopy. It is associated with minimal periportal gas leakage and port dislodgement and is an alternative method for primary cannulation.

Surgical time and motion: the intermediate equivalent revisited.

The relationship between operative time, the intermediate equivalent value (IEV) and the complexity of common general surgical operations was examined. Correlation was found between the BUPA schedule values for procedures categorized as intermediate and major, but complex major vascular reconstruction and oesophagogastric resection for cancer occupied significantly more theatre time than the four intermediate equivalents allocated by the Collins or BUPA schedule. Moreover, anaesthetic preparation time for complex major surgery in the latter surgical subspecialities contributed at least one further intermediate value. Re-evaluation of the ideal IEV weighting of all surgical operations including anaesthetic input from larger similar audits would allow more accurate audits of surgeons' work-load, and also facilitate transparent intensive management of operating theatre resource.

Laparoscopic endogastric pseudocyst gastrostomy: a report of three cases.

The transgastric pseudocyst-gastrostomy is the standard approach for internal drainage of persistent and large retrogastric pancreatic pseudocysts that complicate acute necrotizing pancreatitis. We report on the application of a laparoscopic endogastric approach for drainage of pancreatic pseudocysts and discuss the merits of this technique as well as of the other previously described minimally invasive approaches for the management of pancreatic pseudocysts. Between January 2001 and August 2001, three female patients presented with large symptomatic pseudocysts 3-10 months after an episode of acute necrotizing pancreatitis. Internal drainage was effected by a laparoscopic endogastric pseudocyst gastrostomy, and the necrotic pancreas was debrided. There were no conversions and no postoperative complications. The median postoperative hospital stay was 4 days (range, 3-5). All patients remain asymptomatic, and resolution of the pseudocyst was radiologically evident at a median follow-up of 6 months (range, 4-11). The laparoscopic endogastric pseudocyst gastrostomy appears to be a safe and effective minimally invasive approach for internal drainage of large retrogastric pancreatic pseudocysts and facilitates debridement of the necrotic pancreas.