The Overlapping Running Suture Method Using Single Knotless Barbed Absorbable Suture Material for Abdominal Wall Closure after Single Incision Laparoscopic Appendectomy: Comparison with the Traditional Interrupted Closure Technique

PURPOSE: The aim of our study was to present an abdominal wall closure technique using barbed suture V-Loc™ 90 after single incision laparoscopic appendectomy (SILA) and to compare perioperative outcomes with conventional layer by layer abdominal wall closure after SILA. METHODS: From March 2014 to July 2016, a retrospective case-control study was conducted for a total of 269 consecutive patients who underwent SILA. According to abdominal wall closure methods, 129 patients were classified into the V-Loc closure group and 140 patients were assigned into the conventional layer by layer closure group. In the V-Loc group, abdominal wall closure was performed from the fascia to the skin with a single thread of unidirectional absorbable barbed suture V-Loc™ 90 2-0 using continuous running suture and reverse overlapping reinforced running technique. Subcutaneous closure and subcuticular suture were performed with the remaining portion of V-Loc. RESULTS: The V-Loc closure group showed shorter total operation time (40.0±15.4 min vs. 44.9±16.3 min, p=0.013) and abdominal wall closure time (5.5±0.9 min vs. 6.5±0.8 min, p < 0.001). Postoperative incision length was significantly shorter in the V-Loc closure group (1.1±0.3 cm vs. 1.8±0.4 cm, p < 0.001). Postoperative wound pain, time to resume diet, postoperative hospital stay, complications including surgical site infection, or mean patient satisfaction score at one month after hospital discharge was not significantly different between the two groups. CONCLUSION: In conclusion, unidirectional knotless barbed suture is a safe alternative method for abdominal wall closure after SILA. It can save time while providing comparable cosmesis.

One-year experience with single incision laparoscopic cholecystectomy in a single center: without the use of inverse triangulation

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is generally performed with the use of inverse triangulation. In this study, we performed 3-channel or 4-channel SILC without the use of inverse triangulation. We evaluated the adequacy and feasibility of SILC using our surgical method. METHODS: We retrospectively reviewed our series of 309 SILCs performed between March 2014 and February 2015. RESULTS: Among 309 SILCs, male were 148 and female were 161 patients, mean age was 48.7 +/- 15.3 years old and mean body mass index was 24.8 +/- 3.8 kg/m2. Forty patients had previously undergone abdominal surgery including 6 cases of upper abdominal surgery. SILC after percutaneous transhepatic gallbladder (GB) drainage was completed in 8.7% of cases. There were 10 cases of emergency SILC. SILC was performed for noncomplicated GB including symptomatic GB stone and polyp in 66.7% of cases, acute cholecystitis in 33.3%. Overall, 96.8% of procedures were successfully completed without additional port. The reason for addition of an extra port or open conversion included technical difficulties due to severe adhesion and bleeding. The mean operating time was 60.7 +/- 22.3 minutes. The overall complication rate was 4.8%: 9 patients of wound seroma, 1 case of bile leakage from GB bed, 4 cases of intra-abdominal abscess or fluid collection, and 1 case of incisional hernia were developed. There was no case of common bile duct injury. CONCLUSION: Our surgical method of SILC without the use of inverse triangulation is safe, feasible and effective technique.

Endoscopic Ultrasound-guided Drainage of Fluid Collection on Lesser Sac after Pancreaticoduodenectomy Not Accessible to Percutaneous Drainage / 대한췌담도학회지

Postoperative fluid collection is a major complication after pancreaticoduodenectomy and can lead to increased mortality and hospital length of stay. External drainage has widely been used for postoperative fluid collections. Recently, EUS-guided drainage has also been used successfully in treating postoperative fluid collections. A 60-year-old woman was admitted due to weight loss and jaundice. She underwent pancreaticoduodenectomy for cholangiocarcinoma of the common bile duct. After 2 weeks, she had fever with abdominal pain and leukocytosis. CT showed a increased fluid collection in superior recess of lesser sac and EUS-guided drainage was performed. The symptoms resolved without any complication after drainage. This is the first case report of EUS-guided drainage for lesser sac in Korea.

Laparoscopic treatment for post-cholecystectomy Mirizzi syndrome

The remnant cystic duct or gallbladder neck calculus may rarely result in post-cholecystectomy Mirizzi syndrome. Various managements have been proposed for the treatment of post-cholecystectomy Mirizzi syndrome. Some previous cases of post-cholecystectomy Mirizzi syndrome have been managed with open cholecystectomy and endoscopically. We report a case of a laparoscopic stone removal of post-cholecystectomy Mirizzi syndrome that developed 7 months after laparoscopic cholecystectomy. To our knowledge, this is the first case of laparoscopic management of post-cholecystectomy Mirizzi syndrome. The mechanism, diagnosis and treatment of post-cholecystectomy Mirizzi syndrome are discussed.

Relationship between the risk of bile duct injury during laparoscopic cholecystectomy and the types of preoperative magnetic resonance cholangiopancreatiocography (MRCP)

BACKGROUNDS/AIMS: Bile duct injury is one of the potential severe complications that can occur during laparoscopic cholecystectomy, which can be cause by anatomic variations in the confluence of the bile duct. Recently magnetic resonance cholangiopancreatiocography (MRCP) has become a helpful tool to detect bile duct variation on a preoperative basis and to prevent bile duct injury during laparoscopic cholecystectomy, as well other hepatic surgeries. This study aimed to clarify the types of bile duct on MRCP and to search for a method of avoiding injury during laparoscopic cholecystectomy. METHODS: Between January 2009 and December 2010, 277 patients underwent laparoscopic cholecystectomy with preoperative MRCP in our institution. On a retrospective basis, the bile ducts were categorized into 5 types according to the Couinaud classification system. RESULTS: The proportion of types was revealed type A (70.4%), type B (8.7%), type C (19.5%), type D (0.7%), type E (0%), and type F (0.7%), respectively. Bile duct injury occurred in 4 cases (1.4%) during laparoscopic cholecystectomy. In particular, the possibility of aberrant extrahepatic confluence (Type C and F) represented the highest risk of duct injury (OR=11.89 [CI: 1.21-116.53]). CONCLUSIONS: Preoperative evaluation of the bile duct anatomy is important to avoid injury of duct during laparoscopic cholecystectomy. Specific types of bile duct variation should be considered as a high risk group for bile duct injury.

Cavo-caval intervention stent insertion after deceased-donor liver transplantation using side-to-side piggyback technique: report of a case

Liver transplantation with preservation of the recipient vena cava (piggyback technique) has been performed as an alternative to the conventional method. Outflow disturbance or obstruction of the vena cava in the early period after liver transplantation is associated with high morbidity and mortality. We used side-to-side cavo-caval anastomosis (modified piggyback technique) in a deceased-donor liver transplantation (DDLT) for venous outflow reconstruction. On postoperative day 9, the patient developed abdominal discomfort, and abnormal liver function showing serum total bilirubin of 6.2 mg/dl and serum AST/ALT of 297/597 IU/L. Doppler ultrasound showed mono-phasic wave forms of the hepatic vein. Computed tomography showed focal narrowing of 9.5 mmx12 mm in diameter at the cavo-caval anastomosis site. Liver biopsy was showed that there was no evidence of acute allograft rejection. Direct venogram showed stenosis of the cavo-caval anastomosis with a pressure gradient of 12 mmHg. An interventional stent was inserted in the stenotic site of the inferior vena cava, and the pressure gradient decreased to 2 mmHg. He was discharged from hospital on postoperative day 23 without any other complications. Herein we report a case of deceased-donor liver transplantation using the modified piggyback technique, who received an inferior vena cava stent due to stricture of the reconstructed orifice of the vena cava.

Management of endoscopic retrograde cholangiopancreatography-related perforations / 대한외과학회지

PURPOSE: The purpose of this study is to analyze the treatment strategies of patients with endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. This is a retrospective study. METHODS: We experienced 13 perforations associated with ERCP. We reviewed the medical recordsand classified ERCP-related perforations according to mechanism of injury in terms of perforating device. Injury by endoscopic tip or insertion tube was classified as type I, injury by cannulation catheter or sphincterotomy knife as type II, and injury by guidewire as type III. RESULTS: Of four type I injuries, one case was managed by conservative management after primary closure with a hemoclip during ERCP. The other three patients underwent surgical treatments such as primary closure orpancreatico-duodenectomy. Of five type II injuries, two patients underwent conservative management and the other three cases were managed by surgical treatment such as duodenojejunostomy, duodenal diverticulization and pancreatico-duodenectomy. Of four type III injuries, three patients were managed conservatively and the remaining patient was managed by T-tube choledochostomy. CONCLUSION: Type I injuries require immediate surgical management after EPCP or immediate endoscopic closure during ERCP whenever possible. Type II injuries require surgical or conservative treatment according to intra- and retro-peritoneal dirty fluid collection findings following radiologic evaluation. Type III injuries almost always improve after conservative treatment with endoscopic nasobilliary drainage.

Isolated Celiac Artery Dissection and Splenic Infarction in a Patient with Protein S Deficiency: A Case Report

Protein S (PS) deficiency is a rare blood disorder associated with thrombosis. Only a small number of cases of isolated celiac artery dissection can be found in the literature. We now report a case of isolated celiac artery dissection and splenic infarction in a 44-year old male with PS deficiency. Abdominal computed tomography revealed celiac artery dissection and splenic infarction. The patient's PS activity was 64% (nl : 70~140%) upon admission and 52% four weeks later. He was started on a regimen of NPO, antibiotics, and analgesics. He resumed oral intake of food and drugs on hospital day 3 and was discharged to his home on hospital day 8. We report a case of isolated celiac artery dissection with splenic infarction in a patient with PS deficiency that improved with conservative treatment. The patient's management did not include anti-platelet/thrombotic agents or endovascular/operational procedures.

Benefits of Percutaneous Transhepatic Gallbladder Drainage for Laparoscopic Cholecystectomy in Patients with Acute Cholecystitis

PURPOSE: The purpose of this study was to evaluate surgical outcomes of laparoscopic cholecystectomy (LC) and the effect of preoperative percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis. In particular, we concentrated on differences in surgical outcomes between elective and emergency operations. METHODS: Between March 2006 and February 2009, 259 cases of acute cholecystitis underwent LC at our institution and we studied them retrospectively. They were divided into 3 groups. Group I included 153 patients who underwent elective LC without PTGBD; group II included 90 patients who underwent elective LC after PTGBD; group III included 16 patients who underwent emergency LC without PTGBD. RESULTS: Between groups I and III, there were no differences in conversion rate, postoperative complications, and total hospital stay. However, the operation times and postoperative hospital stays of group I were shorter than those of group III and the difference was significant (p<0.05, p<0.01, respectively). Between groups II and III, there were no differences in operation time, conversion rate, postoperative complications, and postoperative hospital stay. CONCLUSION: We recommend PTGBD for a patient with acute cholecystitis as much as possible, if indicated, so that we can do the operation on the patient as elective surgery and not as an emergency.

DNA Hypermethylation and the Loss of Heterozygosity of Chromosome 16q22 in Hepatocellular Carcinoma

PURPOSE: E-cadherin gene, located on chromosome 16q22, may play crucial roles in the cell adhesion and propensity for more malignant properties of various organs. Although loss of heterozygosity (LOH) and DNA hypermethylation at various chromosomal loci have been reported on many malignant tumors, they have been rarely studied in hepatocarcinogenesis, especially for the E-cadherin gene. Our objectives were to evaluate E-cadherin LOH and hypermethylation in hepatocellular carcinomas (HCC) and to correlate with various clinicopathological facors. METHODS: The LOH analysis was performed by using polymerase chain reaction (PCR) with three polymorphic microsatellite markers (D16S419, D16S3106, D16S498) in 40 surgically resected HCCs and each non-tumorous counterpart. The hypermethylation was studied using methylation specific PCR. RESULTS: LOH and hypermethylation were detected in 35% and 55% of HCC, respectively. Also, LOH and hypermethylation were detected in 0% and 32.5% of non-tumor lesions, respectively. LOH results correlated well with higher tumor histologic grade, tumor size and intrahepatic metastasis or vascular tumor invasion. Hypermethylation results correlated well with presence of cirrhosis. Correlation between LOH and hypermethylation was not recognized, but 45.5% of hypermethylation cases showed LOH detection. CONCLUSION: These results suggest that E-cadherin LOH may be associated with more malignant phenotype and tumor progression. And E-cadherin DNA hypermethylation may participates in the early hepatocarcinogenesis by preceding LOH but not causing LOH.

Perioperative Intensive Care for Liver Transplantation / 대한구급학회지

Many liver recipients have required intensive care, which is individualized and customized to each recipient. Prerequisites qualifying this care are wide comprehension of characteristics of end-stage liver disease and mechanisms of surgical procedures and immunologic knowledge. We present our principles of intensive care and experience from more than 300 cases of liver transplantation. There are roughly two types of liver transplantation, cadaveric and living-donor. These two types are different in their postoperative courses as following; severity of preservation injury, graft-size matching and morphologic liver regeneration and risk of vascular and biliary complications. Intensive care for liver recipients should be directed toward preventive and protective care along reasonable prediction of its clinical course. We described our experience about following subjects: management of hepatorenal syndrome, fulminant hepatic failure, acute renal failure, pneumonia, disturbance of consciousness, prophylaxis of viral hepatitis B, tumor recurrence, use of antibiotics, induction of liver function recovery, maintenance of vital signs, electrolyte balance, diet and infection control, nutritional support. The most important factor is the state of transplanted liver graft in determination of posttransplant course. If the graft functions well, many problems will be solved spontaneously. If not, intensive care will be required. Most of operative complications are related to the surgery itself, so that comprehension to surgical procedures to each recipient should be preceded for early detection and proper management. To achieve a favorable posttransplant course, all factors including maintenance of vital signs, elimination of obstacles to hepatic recovery, appropriate immunosuppression and solution of surgical complications should be met altogether. Of course, every member of liver transplantation team should pay durable attention and dedication to each liver recipient.