A rare psoas hernia: endoscopic diagnosis and management.

Of the various traumatic injuries associated with blunt abdominal trauma, traumatic hernias form a rare and small group. We present a case report of a hernia in the psoas muscle in a 26-year-old lady diagnosed during extraperitoneal repair for inguinal hernia. The hernia was managed laparoscopically by reduction of contents and mesh placement over the defect. This is the first such case reported in the literature till date.

Elective laparoscopy in diagnosis and treatment of recurrent small bowel obstruction.

BACKGROUND: To evaluate the feasibility, efficacy, and safety of laparoscopy in diagnosis and treatment of recurrent small bowel obstruction. METHODS: Retrospective analysis of 253 patients who underwent therapeutic laparoscopy for recurrent small bowel obstruction from June 1996 to May 2005 was carried out. Patients with acute small bowel obstruction, bowel obstruction due to tumor, and obstructed inguinal hernias were excluded from analysis. RESULTS: Laparoscopy diagnosed cause of obstruction in all except 3 (1.18%) patients. The etiology included adhesions (38%), incarcerated ventral incisional hernias (32%), Meckel diverticulum (7%), stricture (14%), volvulus (3%), intussusception (4%). One hundred sixty nine patients were managed totally laparoscopically with adhesiolysis. Therapeutic bowel intervention other than adhesiolysis was required in 84 patients, of which 33 procedures were performed totally laparoscopically and remaining 51 procedures were completed with laparoscopically guided target incision. Five patients required conversion to open celiotomy. Iatrogenic enterotomies occurred in 3 patients and small bowel perforation during manipulation occurred in 1 patient. Postoperative procedure-related complications were seen in 44 patients. There was one mortality due to postoperative arrhythmia and cardiac failure. CONCLUSIONS: Laparoscopic diagnosis and treatment of recurrent small bowel obstruction is feasible, safe, and can be performed electively in selected cases.

Laparoscopic splenectomy for hematologic disorders: experience with the first fifty patients.

BACKGROUND: Splenectomy is increasingly being performed by various minimal access surgical modalities for select hematologic disorders. METHODS: A retrospective analysis was performed on the first 50 patients on whom laparoscopic splenectomy (LS) was attempted. The data studied included indications for surgery, patient demographics, intraoperative parameters, and patient outcomes. A total laparoscopic approach (TLS) was employed in 38 patients and a hand-assisted technique (HALS) was used in 12 patients with massive splenomegaly. Eight patients had concomitant surgical procedures: 7 patients underwent laparoscopic cholecystectomy and 1 patient received a kidney transplant. The most common indications for LS were idiopathic thrombocytopenic purpura (ITP) (50%) and hereditary spherocytosis (24%). RESULTS: LS was successfully completed in 48 patients (96%). Thirty-four patients (68%) required perioperative blood or platelet transfusions. The mean spleen diameter was 17.1 cm (range, 11.2-28.4 cm) on imaging study and mean intact splenic weight was 1019 gm. The mean operative time was 188 minutes (range, 90-340 minutes) in the TLS group and 171 minutes (range, 120-240 minutes) in the HALS group. The mean intraoperative blood loss was 306 mL (range, 40-640 mL) in the TLS group and 163 mL (range, 100-300 mL) in the HALS group. The mean postoperative hospital stay was 3.2 days (range, 2-5 days). CONCLUSION: TLS is safe and feasible in patients with nonpalpable spleens. A concomitant laparoscopic procedure for treating coexisting abdominal pathology may be performed without additional morbidity. The HALS technique may be preferable in patients with splenomegaly (palpable spleens), as it appears to offer intraoperative advantages for retraction, dissection, hemostasis, and organ retrieval.

Laparoscopic cholecystectomy in a patient with ankylosing spondylitis with severe spinal deformity.

Laparoscopic cholecystectomy is the current gold standard for the management of cholelithiasis. As experience with laparoscopic cholecystectomy has increased, contraindications to the procedure have started decreasing. Kyphoscoliosis with fixed rigidity is considered as a relative contraindication to laparoscopic surgery. Ankylosing spondylitis is a challenge to the anaesthesiologist because it is associated with difficult intubation, restrictive ventilatory defects, and frequent cardiac involvement. The benefits of laparoscopic surgery can be extended to this group of patients with severe kyphoscoliosis due to advances in anesthesia and surgical expertise. We report a case of laparoscopic cholecystectomy performed in a patient with severe ankylosing spondylitis with fixed rigidity of the cervical spine and marked thoracolumbar kyphosis with severe restrictive lung disease. The purpose of this report is to describe the difficulties encountered in anesthesia and operative difficulties due to altered body habitus in terms of patient positioning and surgical access.