Contribution of an educational video to surgical education in laparoscopic appendectomy.

OBJECTIVE: With recent widespread advances in laparoscopy, providing education on this subject has become a significant challenge. The aim of this study was to determine the degree of contribution made by surgeons to laparoscopic education through an educational video. MATERIAL AND METHODS: A total of 40 volunteer general surgery residents and specialists participated in our study. Before watching the approximately six-minute educational video prepared for laparoscopic appendectomy, the participants were asked to fill out participant information forms and information measurement questionnaire forms. After the video, the participants were asked to fill out the information measurement questionnaire forms a second time; additionally, attitude evaluation forms and education evaluation questionnaire forms were presented to the participants for completion, and statistical analysis was performed. Furthermore, the total watching duration and the number of times the video was paused were recorded. RESULTS: A total of 40 surgeons participated in the study (75% residents and 25% specialists). When the results of the information determination questionnaire forms filled out by the resident and specialist groups before and after the video were compared, it was observed that the scores of both groups significantly increased after watching the video (p=0.001). A statistical significance was identified between the length of time the video was watched and the education evaluation form scores of the participants (p<0.01). It was observed that the longer the video was watched, the greater the increase in the education evaluation scores. The results of the attitude evaluation forms implied that the video could be produced more professionally. CONCLUSION: Although education is an inevitable requirement of laparoscopic surgery, many teaching methods are available. Awareness-enhancing videos prepared on this topic can be efficient in providing laparoscopic education.

Gallbladder perforation: clinical presentation, predisposing factors, and surgical outcomes of 46 patients.

BACKGROUND/AIMS: We aimed to investigate the clinical features and the relation between patient characteristics and the different types of gallbladder perforation and to determine the predisposing factors. MATERIAL AND METHODS: The medical records of 478 patients who received urgent surgical treatment with the diagnosis of acute cholecystitis and underwent urgent surgery in our clinics between January 1997 and November 2008 were reviewed retrospectively. The demographic data of patients, time elapsed from the onset of the symptoms to the time of surgery, comorbidity status, American Society of Anesthesiologists classification, laboratory data, imaging results, surgical procedures, postoperative complications, and postoperative length of stay of the patients were analyzed. RESULTS: There were 46 (9.6%) patients with the diagnosis of gallbladder perforation. Morbidity and mortality occurred in 15 (32.6%) and 7 (15.2%) patients, respectively. Advanced age, male gender, fever >38°C, high white blood cell count, and presence of cardiovascular comorbidity were found to be significant risk factors for gallbladder perforation. CONCLUSIONS: While early diagnosis and early surgical intervention are the keys to managing gallbladder perforation, we suggest that patients having the above-mentioned clinical features should be carefully investigated.

Spontaneous healing of gallbladder perforation: report of a case.

Gallbladder perforation is a serious complication of acute cholecystitis. Spontaneous healing is very rare, and only three cases have been reported in the English literature. In this study, we present a 73-year-old female patient who underwent a laparoscopic cholecystectomy years after a gallbladder perforation and spontaneous healing.

Effect of sildenafil on wound healing: an experimental study.

PURPOSE: We aimed to investigate the effect of sildenafil on the healing process of abdominal wall wound in rats. MATERIALS AND METHODS: The study was performed with adult female Wistar-Albino rats. Control group (n = 50) were fed on standard laboratory diet until 12 h before surgery. Study group (n = 50) were applied orally with orogastric tube 10 mg/kg once a day for 10 days of sildenafil therapy. Each rat was anesthetized, and a 4-cm-long midline laparotomy was performed. Ten animals from each group were killed at postoperative days (PODs) 4, 7, 14, 21, and 35. Breaking strength analysis was measured, and the abdominal incision wounds were examined histologically. RESULTS: Breaking strength for the midline incision, acute inflammation score on POD 14, and neovascularization on PODs 7, 14, 21, and 35 were significantly higher in the study group. CONCLUSIONS: Sildenafil can be used as a supporting factor in wound healing.

Comparison of a modified anoscope and the purse-string anoscope in stapled haemorrhoidopexy.

AIM: To compare the results of the anoscope of the PPH kit and a modified anoscope during stapled haemorrhoidopexy. METHODS: The hospital records of 37 patients who underwent stapled haemorrhoidopexy between 2001 and 2006 were reviewed. The purse-string suture anoscope in the PPH kit was used on 15 patients (Group 1), and the modified anoscope was used on 22 patients (Group 2). Demographic characteristics of the patients, operation time, surgeon's performance, analgesic requirement, and complications were compared. RESULTS: Operation time was significantly longer in Group 1 (42.0 +/- 8.4 min vs 27.7 +/- 8.0 min, P = 0.039). The surgeons reported their operative performance as significantly better in Group 2 (the results of the assessments were poor in ten, medium in four and good in one in Group 1, while good in all patients in Group 2, P < 0.001). The need for haemostatic sutures was significantly higher in Group 1 (six cases) and was needed in two cases in Group 2 (P = 0.034). CONCLUSION: Operation time decreased and the surgeon's satisfaction increased with use of the modified anoscope, and fewer haemostatic sutures were required if the surgeon waited longer before and after firing the stapler.

Prognostic Factors of Patients With Transmural Advanced Gastric Carcinoma.

BACKGROUND: The purpose of this study is to evaluate perioperative morbidity, mortality and the prognostic factors that influence survival of the patients with transmural advanced gastric carcinoma after curative surgical therapy. METHODS: Fifty patients with transmural advanced gastric adenocarcinoma underwent curative resection in our clinic. The records of the patients were reviewed and the prognostic factors such as age, gender, location and size of the tumor, type of surgery, blood transfusion, depth of tumor invasion, lymph node metastases, stage of the disease, grading, vascular invasion, lymph vessel invasion, characteristics of the tumor according to Lauren's classification, and lymph node ratio were evaluated by using statistical methods. RESULTS: In a total of 12 patients (24%) major morbidities developed, and five patients (10%) died. The overall survival rate was 48% at 1 year, 31% at 3 years, and 19% at 5 years. Lymph node metastases (P = 0.03), lymph vessel invasion (P = 0.001), blood transfusion (P = 0.021), and lymph node ratio (P = 0.006) were the prognostic features identified by univariate analysis. Among the multiple significant prognostic factors in the univariate analysis only one factor, lymph node ratio, proved to be independently significant in the multivariate analysis (RR: 4.47). CONCLUSIONS: Our data showed that we can expect a good survival for patients with a lymph node ratio less than 0.2.

A new technique for presentation of scientific works: video in poster.

BACKGROUND: Presentations at scientific congresses and symposiums can be in two different forms: poster or oral presentation. Each method has some advantages and disadvantages. To combine the advantages of oral and poster presentations, a new presentation type was conceived: "video in poster." METHODS: The top of the portable digital video display (DVD) player is opened 180 degrees to keep the screen and the body of the DVD player in the same plane. The poster is attached to the DVD player and a window is made in the poster to expose the screen of the DVD player so the screen appears as a picture on the poster. Then this video in poster is fixed to the panel. When the DVD player is turned on, the video presentation of the surgical procedure starts. RESULTS: Several posters were presented at different medical congresses in 2007 using the "video in poster" technique, and they received poster awards. CONCLUSIONS: The video in poster combines the advantages of both oral and poster presentations.

Band ligation of the perforated gall bladder during laparoscopic cholecystectomy.

Perforation of the gall bladder is a frequent complication during laparoscopic cholecystectomy. Grasping the perforated part of the gall bladder, clip application, or endoscopic loop application are possible solutions to prevent spillage. We propose laparoscopic rubber band application to close the perforated part of the gall bladder as an easy and safe method. We performed rubber band application after iatrogenic perforation of the gall bladder during laparoscopic cholecystectomy in 5 patients. Two-millimeter-wide multiple rubber rings, cut from a 14-Fr Foley catheter, are loaded on a grasper. When a perforation occurred during the dissection of the gall bladder, the hole is grasped with this instrument and 1 of the rings is placed on the gall bladder by the aid of a dissector. Thus, the grasper remained available for traction of the Hartmann's pouch during further dissection of the gall bladder. The rubber bands were placed successfully in all cases. Two perforations occurred in 1 case, and 2 bands were placed with ease. Bile leakage or gall stone spillage did not occur. Operation time was not prolonged. Rubber band ligation of perforation of the gall bladder is a simple, safe, inexpensive, and effective method to prevent spillage of the bile or gallstones in laparoscopic surgery.

Surgical treatment of hepatic injury: morbidity and mortality analysis of 109 cases.

BACKGROUND/AIMS: We aimed to determine the factors that affect morbidity and mortality in patients that underwent surgery for hepatic injury. METHODOLOGY: Records of 109 blunt or penetrating hepatic trauma patients that underwent surgery in the Third Surgical Clinic of Izmir Atattürk Training and Research Hospital between 1994 and 2004 were reviewed retrospectively. Evaluated parameters were: age, gender, cause of injury, diagnostic procedures, preoperative blood pressure (BP), hemoglobin (Hb) level, amount of intraabdominal blood, associated injuries, the number of involved hepatic segments and anatomic distribution, severity of injury, abdominal trauma index (ATI), amount of blood transfusions, type of surgery, hospital stay, and rates of morbidity and mortality. RESULTS: Median age of the patients was 29 years. The injury was penetrating in 53.2% of the patients and blunt in 46.8%. Abdominal blood was 500cc or less in 70 (64.2%) patients. Isolated hepatic injury was encountered in 29 (26.6%) cases. 22.9% of the patients had major injuries. Hemostasis was achieved by electrocautery, sponge-gel, primary suturing, hepatic resection or perihepatic packing. Morbidity and mortality rates were 40.4% and 14.6% respectively. CONCLUSIONS: Age, type of the injury, BP and Hb levels, amount of intraabdominal blood, degree of injury, ATI, and accompanying organ injuries significantly affect morbidity and/or mortality.

Survival analysis after surgical treatment of gastric cancer: review of 121 cases.

BACKGROUND/AIMS: This study was performed to evaluate major morbidity, early mortality and to analyze survival in our patients that underwent surgical treatment for gastric cancer. METHODOLOGY: Records of 121 patients with gastric adenocarcinoma that underwent surgery between 1997 and 2004 were reviewed retrospectively. Age, gender, tumor site, presence of local invasion, depth of tumor invasion, lymph node metastases, stage of the disease, distant metastases, histological differentiation, type of surgery, and blood transfusions were evaluated in relation to survival. Survival curves were estimated using the Kaplan-Meier method and the differences in survival were compared by the log-rank test. RESULTS: Forty-two cases (34.7%) underwent total gastrectomy, 34 (28.1%) had subtotal gastrectomy, and 45 (37.2%) received palliative surgery. The majority of the patients (61.2%) had stage IV gastric cancer. Total morbidity and mortality were 26.4% and 17.3%, respectively. The factors that influence survival were type of surgery, adjacent organ invasion, existence of metastases, lymph node status, blood transfusions, and stage of the disease in this study. Among the significant prognostic factors in the univariate analysis, only one factor, R0 resection proved to be independently significant in the multivariate analysis. CONCLUSIONS: R0 resection was found to have a significant favorable effect on survival in our study.

Palliative surgery for advanced stage (stage IV) gastric adenocarcinoma.

BACKGROUND/AIMS: The factors that effect resectability, major morbidity, early mortality, and survival in advanced stage gastric adenocarcinoma patients are evaluated. METHODOLOGY: Records of 74 patients that underwent surgery for stage IV gastric adenocarcinoma in the Third Surgical Clinic of Izmir Atatürk Training Hospital between January 1997 and January 2004 were reviewed retrospectively. Two groups (the patients with resectable disease and those with unresectable disease) were compared with regard to age, gender, primary complaint, symptoms, site of the tumor, involvement of adjacent organs, lymph node involvement, distant metastases, differentiation of tumor, surgical procedure, perioperative blood transfusions, and postoperative hospital stay. RESULTS: Mean age of the 74 patients was 58.4 years. Forty-five cases (60.8%) were considered as unresectable and 29 (39.2%) patients underwent a palliative resection. There was a significant relation between resectability and site of the tumor, and severity of invasion. As the number of perioperative blood transfusions increased, morbidity and mortality increased significantly. Although early mortality was high in the palliative resection group, survival (mean 10.4 months, longest 25 months) was better compared to that of the unresectable gastric cancer group (mean 3.5 months, longest eight months). CONCLUSIONS: A palliative gastric surgery may be applied to improve prognosis of advanced gastric cancer patients, even at the presence of peritoneal dissemination, hepatic metastases, N3 lymph node involvement, adjacent organ invasion, or poor differentiation of the tumor.

Special anoscope for easy purse-string suture application in stapled hemorrhoidopexy.

BACKGROUND: Internal hemorrhoids and loose rectal mucosa may block exposure during the purse-string suturing in stapled hemorrhoidopexy, and this may lead to complications. MATERIALS AND METHODS: To retract the prolapsing rectal mucosa, we modified the purse-string anoscope of the PPH01 kit (Ethicon-Endosurgery, Cincinnati, OH, USA) and produced a special anoscope. The open part of the purse-string suture anoscope is covered by transparent acrylic (Orthoacryl, Dentaurum, Pforzheim, Germany). The covering had completely cylindrical outer and inner surfaces and was thin enough to let the anoscope easily rotate in the anal dilator and to let the 26 mm curved, round-bodied needle of the 2/0 polypropylene suture move in the anoscope. A window, 3 cm long and 3-4 mm wide, was opened at the angled part of the anoscope 2 cm to the tip. This special anoscope was used for the purse-string suture during the stapled hemorrhoidopexy procedure in five patients. RESULTS AND CONCLUSIONS: No postoperative complications, early or late, were encountered, and we propose that stapled hemorrhoidopexy procedure can be applied more easily by using this special anoscope.

Acute intraperitoneal rupture of hydatid cysts.

BACKGROUND: Rupture into the abdominal cavity is a rare but serious complication of hydatid disease. The cysts may be ruptured after a trauma, or spontaneously as a result of increased intracystic pressure. Rupture of the hydatid cyst requires emergency surgical intervention. METHODS: Seventeen patients received surgical treatment for intraperitoneal rupture of the cysts over a period of 18 years. Age, gender, time to surgery from the onset of the symptoms, laboratory findings, diagnostic procedures, surgical treatment modalities, in-hospital stay, morbidity, mortality and recurrence were evaluated retrospectively. RESULTS: Five cases (29.4%) had a history of blunt abdominal trauma. Ultrasonography scans revealed intra-abdominal fluid in all cases. Intraperitoneal multiple cysts with heterogeneous cavity or cystic structures in the liver were shown in 14 cases. Computed tomography and magnetic resonance imaging showed multiple cystic lesions in the liver and peritoneum with intra-abdominal free fluid. Procedures to fill the cystic cavities were applied after removal of the intraperitoneal fluid. Four patients (23.5%) died in the early postoperative period. A total of nine morbidities developed in six patients (35.3%). Median hospital stay was 18 days and median follow-up was 78 months. Intra-abdominal recurrence occurred in one case (7.7%). CONCLUSIONS: Rupture of hydatid cysts into the peritoneal cavity, although rare, presents a challenge for surgeons. This pathology should be included in the differential diagnosis of acute abdomen in endemic areas. Computed tomography scan, in addition to clinical presentation, is essential for diagnosis. Emergency surgery is the main treatment for acute ruptured hydatid cysts. The morbidity and mortality rates of surgical interventions for ruptured hydatid cysts are higher than the rates for elective uncomplicated cases.

Gastrointestinal stromal tumors (GISTs): analysis of 20 cases.

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GISTs) are soft tissue sarcomas arising from the mesenchymal tissues in the gastrointestinal tract. Diagnosis, treatment and follow-up protocols of GISTs have not been exactly defined. In this study, twenty cases with GISTs treated in our clinic are examined retrospectively. METHODOLOGY: Twenty cases treated for GISTs in Izmir Atatürk Training and Research Hospital between the years 1999 and 2004 were reviewed retrospectively. Age, gender, clinical findings, diagnostic methods, intraoperative findings, type of surgery, histopathological findings and survival of the patients were evaluated. RESULTS: Fifteen of the cases were male (75%) and five were female (25%), with a median age of 55 years (35-80). The most frequent symptoms were abdominal pain and acute gastrointestinal bleeding. Tumors were gastric (40%), small intestinal (45%), colonic (10%) or rectal (5%). The median tumor size was 9.1 centimeters. Pathological evaluation showed that number of mitoses per 50 high-power field (hpf) was more than five in nine of 10 cases and CD-117 was positive in four of four cases. The mean follow-up period was 21 (1-72) months, and median survival was 21 (1-72) months. CONCLUSIONS: The prognosis of GIST is frequently related to the tumor size and rate of mitosis. Despite the recent demonstration of C-kit protooncogene and introduction of imatinib mesilate as a new chance in treatment, radical surgery remains to be the most effective treatment of GISTs.

Diagnosis and treatment of gallbladder perforation.

AIM: To present our clinical experience with gallbladder perforation cases. METHODS: Records of 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our clinic between 1997 and 2006 were reviewed retrospectively. Sixteen (4.8%) of those patients had gallbladder perforation. The parameters including age, gender, time from the onset of symptoms to the time of surgery, diagnostic procedures, surgical treatment, morbidity, and mortality were evaluated. RESULTS: Seven patients had type I gallbladder perforation, 7 type II gallbladder perforation, and 2 type III gallbladder perforation according to Niemeier's classification. The patients underwent surgery after administration of intravenous electrolyte solutions, and were treated with analgesics and antibiotics within the first 36 h (mean 9 h) after admission. Two patients died of sepsis and multiple organ failure in the early postoperative period. Subhepatic abscess, pelvic abscess, pneumonia, pancreatitis, and acute renal failure were found in 6 patients. CONCLUSION: Early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance. Upper abdominal computerized tomography for acute cholecystitis patients may contribute to the preoperative diagnosis of gallbladder perforation.

Effect of perioperative feeding with fibre & arginine on morphometrics of ileum after surgical stress.

BACKGROUND & OBJECTIVE: Major surgeries as well as other types of injury have been shown to affect the gut function. Enteral diets influence intestinal mucosal morphometry to different extents depending on their composition. Little is known about the effects of these defined-formula diets in patients with surgical stress but no malnutrition. This experimental study was undertaken to compare the effects of different enteral diets on the mucosal morphometrics of small bowel in surgically stressed rats without malnutrition METHODS: Male Wistar-Albino rats (n=84) weighing between 160-220 g were randomised into three groups. Group A received standard rat chow. Group B received a complete balanced nutrition supplemented with fibre, and the rats in Group C were given an isocaloric specialized elemental nutrition enriched with specific combination of nutrients and arginine. The feeding was started two days before the operation and continued until re-operation. Laparotomy, ileal transection, and end-to-end anastomosis was performed as the surgical procedure. The rats were sacrificed on days 0, 2 and 7 post-operatively. One cm of ileal segment containing the anastomosis was examined histologically. Parameters for intestinal mucosal morphometry (number of villi, villous height, mucosal thickness) and number of mucous containing cells were determined. RESULTS: Number of mucous cells per villus was significantly (P<0.05) higher in group A compared to groups B and C on days 0 and 2 post-operation. On day 7 villous height and mucosal thickness were also significantly higher in group A compared to the other two groups. INTERPRETATION & CONCLUSION: Laparotomy and a minor surgical intervention such as small bowel transection was not a major surgical stress for intestinal mucosal atrophy in rats without malnutrition. The effect of fibre and arginine enriched defined-formula diets did not seem to improve intestinal mucosal changes in such a surgical stress model compared with normal rat chow.

Total gastrectomy for gastric carcinoma.

BACKGROUND/AIMS: Gastric cancer is one of the most common organ cancers all around the world and surgical resection is essential for treatment. Total gastrectomy is the procedure of choice for treatment of proximal gastric cancer. Mortality and morbidity risks of this procedure are high, especially among the elderly. METHODOLOGY: Thirty-eight gastric cancer patients underwent total gastrectomy in the Third Surgical Clinic of Izmir Ataturk Training and Research Hospital between 1996 and 2001. Age, gender, location of the tumor, histopathological findings, TNM stage, type of anastomosis, operation time, blood transfusions, oral food intake, postoperative hospital stay, morbidity, mortality both early and late, and survival rate were evaluated. RESULTS: Mean age of the patients was 59.5 years (22-85 years). Sites of the tumors were: cardia 28.9%, cardia and corpus 15.8%, corpus 34.3%, corpus and antrum 18.4%, linitis plastica 2.6%. Histological types were adenocarcinoma (97.4%), and squamous cell carcinoma (2.6%). TNM stages were: stage la 2.6%, stage II 7.9%, stage IIIa 39.5%, stage IIIb 42.1%, and stage IV 7.9%. Esophagojejunostomies were performed manually (34.3%) or by circular staplers (65.7%). Operation time ranged between 3 and 6.5 hours. Gastric tubes were removed on the fourth postoperative day. Average postoperative hospital stay was 12.9 days. Postoperative morbidity was 21%. Wound infection occurred in three patients (7.9%), pulmonary infection occurred in two patients (5.2%) and anastomotic stricture developed in three patients (7.9%). Hospital mortality was 20%. Anastomotic leak occurred in five cases (13.2%) and all died on days 8, 13, 14, 26, and 30. Three patients (7.9%) died of cardiac complications on days 1, 5, and 29. Twelve patients survived for less than one year and eight patients survived for one to two years. Average survival was 10.5 months for 20 out of 30 patients (median 8 months). Ten patients are still alive after 14.3 months. Four patients have been living for less than one year, another four patients for one to two years, and two patients for more than two years. CONCLUSIONS: Total gastrectomy, either performed with a curative or palliative aim, is a safe procedure with acceptable mortality rates. 89.5% of our cases were stage III or IV resulting in a low survival rate. Longer survival rates can be achieved in patients with comparatively earlier stages.

Primary tumors of the small bowel: diagnosis, treatment and prognostic factors.

BACKGROUND/AIMS: The neoplasms of the small intestine are rare and the preoperative diagnosis is difficult. The aim of this study is to review difficulties in diagnosis, treatment options and important prognostic factors. METHODOLOGY: Fifteen patients who underwent surgical resection for intestinal tumors from 1990 to 2000 in the Third Surgical Clinic of Izmir Atatürk Training and Research Hospital were reviewed retrospectively. Age, symptoms, diagnostic methods, operative procedures, and their effects on prognosis were evaluated. RESULTS: Seven patients were male and eight were female. The mean age was 52.3 years (27-77). Eight patients underwent urgent intervention and seven had elective surgery. Three cases were diagnosed as small bowel tumor preoperatively. The radical resection of the small bowel neoplasm was possible in 12 patients (80%), eight of whom being malignant and four of whom being leiomyoma. Three patients with leiomyoma are still alive for 3.5, 6 and 9 years but one patient died perioperatively because of respiratory distress syndrome. Two cases with lymphoma survived for 16 and 37 months while another two have been still alive for 7 and 8 years. The patients who had malignant epithelial tumor, leiomyosarcoma, and malignant mesenchymal tumor survived for 17, 54, and 20 months, respectively. The patient with malignant tumor of endocrine origin has still been living for 3 years. CONCLUSIONS: As a result we concluded that better evaluation of signs and symptoms may facilitate the diagnosis; and the most important prognostic factors are early diagnosis and radical surgery.

A patient with liver trauma and incomplete behcet s disease.

Behcet' s Disease (BD ) is a complex multisystemic disease, which is characterized by recurrent oral and genital aphteous ulcers and iritis in which vasculitis can also be one of the possible clinical manifestations. A thirty seven year-old female patient with incomplete BD was admitted to emergency service, with intra-abdominal hemorrhage more severe than that would be expected, with the degree of related trauma. We decided to manage the patient conservatively, observing vital signs, haemogram, computed tomography (CT) and angiography instead. Subcapsular hematomas were detected in the right and left lobes of the liver. No data was encountered in the literature and textbooks referring to liver trauma with BD, except a case of fatal hemobilia. H ere in we present a liver trauma case with hemorrhage and hepatic fragility due to vasculitis in Behcet' s disease and review the literature. Key words: liver trauma, incomplete Behcet' s disease