A new technique of laparoscopic obturator hernia repair: report of a case.

An 84-year-old woman presented with ileus. Ultrasonography, a computed tomography scan, and small bowel contrast examination showed a Richter-type hernia in her left obturator orifice. Under general anesthesia, laparoscopic surgery with low-pressure (4mmHg) pneumoperitoneum was carried out using a peritoneal needle retractor, and a reduction of the strangulated intestinal loop was thus achieved. Because the hernial opening measured 5mm in diameter, it could be closed with four pieces of End-Universal stapler without polypropylene mesh. The ischemic ileum was resected, and the bowel was anastomosed extracorporeally with a minimal skin incision. She was ambulant on the first postoperative day, and her postoperative course was good. Obturator hernias are rare, but when a definitive diagnosis is made in such elderly patients, laparoscopic repair using the peritoneal needle retractor is recommended for minimally invasive surgery. We recommend doing the repair with an End-Universal stapler, since this procedure is more simple and useful for preventing infection than using polypropylene mesh in such a strangulated case.

The doughnut sign: an ultrasound finding in pediatric intestinal Burkitt's lymphoma.

This paper describes a doughnut-like ultrasound (US) finding in pediatric intestinal Burkitt's lymphoma. A 9-year-old boy had a fist-sized, hard, non-movable mass in the lower abdomen. US showed a thickened, layered ring like a doughnut. The outer, low-level echoes seemed to be consistent with mucosa and muscle layers and the inner, high-level echoes seemed to be intraluminal air or mucus. The serum lactic dehydrogenase level was high. At surgery, a solid, hard tumor 15 x 10 cm in size was found in the jejunum. The intestinal wall was diffusely thickened with an intact mucosa. From this experience, the US doughnut sign may be a helpful diagnostic finding in pediatric intestinal Burkitt's lymphoma.

Transumbilical resection and umbilical plasty for patent omphalomesenteric duct.

This paper describes a transumbilical resection and umbilical plasty for treatment of a patent omphalomesenteric duct (POMD). In a newborn infant with a POMD, a skin incision was made circumscribing the mucocutaneous junction of the protruded duct. The duct was completely extirpated with a wedge resection of the connection to the intestine and an umbilical plasty was performed. The postoperative appearance was excellent. It appears that transumbilical resection and umbilical plasty may be a satisfactory operation for POMD.

Abdominal wall plasty for a premature infant with congenital diaphragmatic hernia.

This paper reports a premature infant with a congenital diaphragmatic hernia (CDH) who underwent an abdominal wall plasty to enlarge the abdominal cavity, one of twin infants born at 32 weeks weighing 1,255 g. After stabilization, the herniated viscera were reduced from the pleural cavity and the abdominal wall muscle and skin layers were replaced by a Gore-tex patch without closure of the diaphragmatic defect. Respiratory and circulatory conditions were stable during the perioperative period. Postoperatively, a roentogenogram showed expansion of the lung. However, his condition deteriorated 24 h after surgery, triggered by intratracheal suction, and he died on the 4th day of life despite the use of high-frequency oscillation, catecholamines, and vasodilators. Postmortem examination showed severely hypoplastic lungs. Abdominal wall plasty may be a less invasive initial procedure, however, further studies, such as comparison with the standard method or conservative management, are needed using a large clinical group or animal models to justify the usefulness of this procedure.

Laparoscopic cholecystectomy and time-course changes in renal function. The effect of the retraction method on renal function.

BACKGROUND: Recently, the retraction method has been used to reduce intraabdominal pressure (IAP) during laparoscopic surgery. The purpose of this study was to determine the serial changes in renal function during laparoscopic cholecystectomy (LC) using the retraction method. METHODS: Urine output, effective renal plasma flow (ERPF), and glomerular filtration rate (GFR) were measured serially in seven patients who underwent LC with 12 mmHg pneumoperitoneum (High-IAP group) and five who underwent LC using the retraction method with 4 mmHg pneumoperitoneum (Low-IAP group). RESULTS: Urine output, ERPF, and GFR were decreased during pneumoperitoneum in the High-IAP group, whereas no significant changes in any of these parameters were observed in the Low-IAP group. CONCLUSIONS: Our findings demonstrate that reduction of IAP to 4 mmHg using the retraction method prevents the transient renal dysfunction caused by prolonged 12 mmHg pneumoperitoneum during LC, suggesting that the retraction method reduces the risk of perioperative renal dysfunction during laparoscopic surgery.

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10 - 60 min under an insufflation pressure of 10 - 12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.

Laparoscopic diagnosis of blunt abdominal trauma in children.

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10 - 60 min under an insufflation pressure of 10 - 12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.

Necrotizing enterocolitis in a term infant with coarctation of the aorta complex.

Necrotizing enterocolitis (NEC) sometimes occurs in term infants with congenital heart disease. This article reports a rare case of a term infant with coarctation of the aorta complex who developed NEC on the 8th day after birth. Spontaneous closure of the ductus arteriosus in the 1st week of life may cause intestinal ischemia and hypoxia with resultant NEC.

Congenital multiple intestinal atresia successfully treated with multiple anastomoses in a premature neonate: report of a case.

We report herein the case of a 2080-g premature male infant born at 34 weeks' gestation with multiple intestinal atresia, for whom multiple anastomoses were successfully performed. A total of 11 atresias were found in the small bowel, and five anastomoses were performed to preserve 59 cm of small bowel and the ileocecal valve. Postoperatively, he developed several episodes of sepsis caused by persistent enterostasis, but was able to be weaned from total parenteral nutrition (TPN) by postoperative day (POD) 106. Thus, multiple anastomoses may be the appropriate procedure to prevent short-gut syndrome for congenital multiple intestinal atresia, even in premature infants.

Infarcted intestinal volvulus detected by prenatal ultrasonography.

This article describes a prenatal ultrasonographic finding of an infarcted intestinal volvulus. Ultrasonography showed polyhydramnios, multiple dilated intestinal loops, increased transverse abdominal area, and ascites. After cesarean section due to premature rupture of membranes and fetal distress, derotation of the infarcted volvulus caused postoperative thrombocytopenia, hyperkalemia, and acidosis and a subsequent resection was required. A high output of intestinal juice from the jejunostomy caused severe hypovolemia and electrolyte imbalance with resultant death. Increased transverse abdominal area caused by marked intestinal dilatation, ascites, fetal distress, and hydrops fetalis may suggest an infarcted intestinal volvulus.

[Experience with radical operation for lower thoracic esophageal cancer through left diagonal thoraco-laparotomy and right posterolateral thoracotomy].

Two cases were reported in which subtotal thoracic esophagectomy, total gastrectomy, splenectomy and distal pancreatectomy was performed for the lower thoracic esophageal cancer through right diagonal thoraco-laparotomy and left posterolateral thoracotomy. Reconstruction was done with the intrathoracic esophagojejunostomy. Extubation could be done on the 1st postoperative day, and postoperative course was uneventful. It was thought that the approach with left diagonal thoraco-laparotomy and right posterolateral thoracotomy was useful for the easy and complete lymph node dissection from the middle mediastinum to the intra-abdominal cavity.

[A five-year-survival case in which complete response was recognized after combined chemotherapy using 5-fluorouracil, adriamycin and mitomycin C (FAM) for unresectable gastric cancer].

FAM (5-fluorouracil, adriamycin, mitomycin C) therapy was performed on a 65-year-old man with unresectable gastric cancer. Cancer cells have not been recognized by endoscopic biopsy after the patient's complete response. He is alive without metastasis of recurrence for five years.

Primary malignant lymphoma of the spleen.

We treated two patients with primary splenic malignant lymphoma. One was a 63-year-old man with diffuse histiocytic non-Hodgkin's lymphoma accompanied by multiple liver metastases which were composed of necrotic tissue probably due to preoperative transarterial chemoembolization (TAE). He eventually died of liver failure two years and six months after splenectomy. The autopsy revealed that a large part of the cirrhotic liver had been occupied by a diffuse-type hepatocellular carcinoma, but no recurrence of the malignant lymphoma was found in the liver or other organs. The second patient was a 40-year-old woman with a massive invasion of the stomach, colon, pancreas, and diaphragm by a splenic tumor. The splenic tumor and the adjacent involved organs were resected. Pathologically, well-differentiated diffuse lymphocytic non-Hodgkin's malignant lymphoma was evident. No recurrence has been found for six years and two months. Based on an evaluation of the 71 patients with primary splenic malignant lymphoma reported to data in Japan, the patients treated by a curative resection in an early clinical stage have a more favorable prognosis.

[Thyroid cancer metastasis to the lumbar spine successfully treated by embolization and radioiodine. A case report].

A 82-year-old woman suffered from a metastatic lesion of follicular carcinoma of the thyroid to the fourth lumbar spine, which compressed the spinal nerves and caused lumbar pain and paresthesis of the lower limb. External irradiation, 5200 RAD, was carried out. Total thyroidectomy was done for the preparation of radioiodine(131I) therapy. Two weeks later, embolization of lumbar arteries was performed to prevent the progression of the spinal cord damage during a period waiting for 131I administration. The size of the lumbar lesion decreased, and lumbal pain and spinal cord symptoms disappeared. After administration of 131I, the metastatic lesion became further smaller.

Different patterns of leakage of cytosolic and mitochondrial enzymes.

The mechanisms of leakage of intracellular enzymes, and especially the cytosolic and mitochondrial isozymes of aspartate aminotransferase (AST), in ischemic rat liver were studied. On recirculation of ischemic liver, cytosolic AST (cAST) promptly appeared in the blood. Release of cytosolic enzymes, including cAST and lactic dehydrogenase, resulted from disruption of blebs that protruded from parenchymal cells into the sinusoidal space. When these blebs were formed in ischemic liver, mitochondria still remained in core regions of the injured cells and were not found in the blebs. Consistent with this fact, mitochondrial AST (mAST) did not leak into the circulation from ischemic liver until most of the cAST had leaked out. This delayed leakage of mitochondrial enzymes was also consistent with the fact that the mitochondrial membranes maintained a diffusion barrier against matrix enzymes even after anoxia for 2 h, when their oxidative phosphorylation capacity had been lost. These results indicate that mitochondrial enzymes are liberated into the blood only after appreciable disintegration of the cells, probably necrosis, and that the cumulative activity of mAST in the blood should reflect the extent of necrosis in ischemic organs better than that of cAST.

Vertebral aneurysm of the neck.

We recently encountered a case of a huge vertebral aneurysm involving the entire right neck, extending from the clavicle to the mandibular area. The patient had undergone laminectomy of the cervical spine at age 45 for neuritis or spinal caries. This operative procedure apparently caused a small vertebral laceration and produced the giant aneurysm. The aneurysm was resected under hypothermia in order to protect the brain. One vertebral artery was ligated, but cerebral damage did not occur. Only a few cases of huge aneurysms extending from the clavicle to the mandible have been reported in the literature.

[A case of carotid body tumor. A review of 84 cases in Japanese literature].

We encountered one case of carotid body tumor. The patient was a 63-year-old man. The tumor was 5 cm X 6 cm in size, and it was strongly adhered to the carotid artery. Therefore, the tumor was removed with combined resection of the adherent lesion of the carotid artery. During the operation, we used a temporary external bypass method to prevent brain damage. The resected part of the carotid artery was reconstructed with saphenous vein graft. Angiogram one year after operation showed good patency of the graft. In Japanese literature, this is the second report of carotid body tumor removed by temporary bypass and the first report of use of a external bypass tube.