Transumbilical Laparoscopic Cholecystectomy with Additional Port: A Single Surgeon's Experience with 291 Cases

PURPOSE: Single-port laparoscopic cholecystectomy may result in postoperative complication in patients with cholecystitis. An additional right subcostal port could make laparoscopic surgery safe in these patients. We suggest the transumbilical laparoscopic cholecystectomy with additional port, which can be performed safely regardless of cholecystitis. METHODS: Consecutive 291 patients underwent transumbilical laparoscopic cholecystectomy in the Department of Surgery by a single surgeon. We have usually used the globe port in the transumbilical area and an additional right subcostal port. RESULTS: The mean operation time was 44.0+/-15.2 min (range: 20-140). The mean hospital stay after operation was 4.0+/-2.3 days (range: 1-9). Postoperative complications were umbilical hernia (n=7) and bile leakage (n=3). There was no in-hospital mortality. CONCLUSION: Transumbilical laparoscopic cholecystectomy can be performed in patients with most of benign gallbladder disease. And, an additional right subcostal port could be helpful in ensuring safe transumbilical laparoscopic cholecystectomy, even in patients with cholecystitis.

Transumbilical Laparoscopic Assisted Single Port Appendectomy (Hybrid Appendectomy) in Children

PURPOSE: Laparoscopic appendectomy isused as a three port technique for appendectomy. In children, single port laparoscopic appendectomy is difficult because they have a small peritoneal cavity for manipulation of laparoscopic instruments. We performed transumbilical laparoscopic assisted single port appendectomy (hybrid appendectomy) in children. METHODS: From March 2010 to July 2012, we performed transumbilical laparoscopic assisted single port appendectomy in 53 children. We made a vertical incision to the umbilicus approximately 1.5 cm, and a wound retractor (Applied Medical Resources Co., Ltd., Rancho Santa Margarita) was placed in the umbilical incision, and appendix exteriorized the extraperitoneum through the wound retractor. Appendectomy was performed conventionally. We had no conversion cases for laparotomy. RESULTS: A total of 53 patients, 29 females and 24 males, with a mean age of 8.5+/-2.0 years were enrolled in this retrospective study. The mean operative time was 29.4+/-9.4 minutes. There was no occurrence of complication or mortality. BMI was 17.8+/-4.9 kg/m2. And mean hospital stay was 3.2+/-1.0 days. CONCLUSION: In children, transumbilical single port laparoscopic appendectomy is technically difficult because they have a small peritoneal cavity. However, transumbilical laparoscopic assisted single port appendectomy (hybrid appendectomy) appearsto be a safe and effective technique for use in children, which allows for achievement of nearly scarless surgery.

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.

Acute, fatal postoperative myocardial infarction after laparoscopic cholecystectomy in a cardiac patient: A case report / 대한마취과학회지

This report presents the case of a 63-year-old man who had a myocardial infarction leading to coronary artery bypass graft 2 years earlier who subsequently underwent elective laparoscopic cholecystectomy. After an uneventful operation, the patient developed an acute postoperative myocardial infarction in the recovery room and died 19 days postoperatively. Anesthesiologists should be aware of the rare possibility of acute, fatal postoperative myocardial infarction and consider this complication when they perform the preoperative risk evaluation, anesthesia, and postoperative care for cardiac patients undergoing noncardiac surgery.

Gastric Polyposis Associated with Gastric Cancer

Gastric polyps encompass a wide variety of lesions that most commonly arise from the gastric epithelium. However, coincidental gastric carcinomas have rarely been reported, being found in only 2~3% of patients with hyperplastic polyps. A 68-year-old male was admitted to our hospital for bleeding control of a gastric polyp. The gastroscopy shows numerous polyps in the entire gastric mucosa and a huge ulcer with bleeding. The bleeding of the gastric ulcer could not be controlled by gastroscopic procedures. So, we performed total gastrectomy for bleeding control. The pathologic findings shows poorly differentiated adenocarcinoma with hyperplastic polyps. We performed treatment with Cisplatin and 5-FU for two cycles. Two months postoperative, he was admitted due to dyspnea associated with ascites. We performed a ckeckup by computer tomography. It revealed cancer recurrence with lymphatic and liver metastasis, and diffuse massive ascites with mesenteric cake, and it suggested cancer peritonei.

Laparoscopic versus Open Appendectomy for Complicated Appendicitis / 대한내시경복강경외과학회지

PURPOSE: The value of laparoscopic appendectomy for complicated appendicitis is still controversial. The purpose of this clinical study was to evaluate the efficacy of laparoscopic appendectomy in patients with complicated appendicitis. METHODS: This study involved a total of 108 consecutive patients who had undergone appendectomy for complicated appendicitis between January 2008 and August 2009. Those patients were divided into two groups; laparoscopic appendectomy (LA) and open appendectomy (OA). The demographic data, the incidence of drainage tube insertion, the operative time, the duration of pain, the time to a soft oral diet, the hospital days and the complication rate for the two groups were analyzed. RESULTS: There were no significant differences of the operative time (OA group: 65.2+/-27.31 min vs the LA group: 64.6+/-23.6 min) (p=0.233). However, in the LA group, there were benefits for number of drainage tube insertions (OA group: 48/60 vs the LA group: 8/48) (p<0.001), the use of analgesics (OA group: 3.2+/-3.9 times vs the LA group: 1.4+/-1.3 times) (p<0.001), the time to start a soft diet (OA group: 2.8+/-1.3 days vs the LA group: 1.4+/-1.3 days) (p=0.020), the hospital stay (OA group 7.5+/-3.4 days vs LA group 3.7+/-2.2 days) (p=0.040) and the complication rate (OA group: 18/60 vs the LA group: 8/48) (p<0.001). CONCLUSION: These results suggest that laparoscopic appendectomy for treating complicated appendicitis is a safe procedure that may prove to have significant clinical advantages over open appendectomy.

Trans-umbilical Single Port Laparoscopic Appendectomy: Initial Experience / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy is one of the most commonly performed minimally invasive surgeries worldwide. In recent years, successful attempts to reduce the number of conventionally-used three ports have been reported. Specifically, two-port techniques, hybrid approaches and single-port assisted techniques have been described. In this article, we report on the feasibility, safety and cosmesis of trans-umbilical single port laparoscopic appendectomy. METHODS: The procedure was performed using a single 15-mm-diameter umbilical incision. Under general anesthesia, an Alexis O wound retractor (Applied medical resources Co., Ltd., rancho Santa Margarita) was inserted through the umbilicus. After the appendix and meso-appendix were dissected with a Harmonic scalpel (Ethicon Endo-Surgery, Inc., USA), the base of the appendix was ligated with two Endo-loops (SEOJONG medical Co., Ltd., Korea). The appendix was withdrawn into the wound protector and removed from the abdominal cavity. RESULTS: This retrospective study enrolled 70 patients (36 females and 34 males with a mean age of 29.0+/-15.0 years). The mean operative time was 49.0+/-13.9 min. There was no mortality. There were five complications in five patients (7.1%) and the median hospital stay was 3.5+/-1.4 days. CONCLUSION: This is a safe, minimally invasive procedure with excellent cosmetic results. Compared with other trans-umbilical appendectomy techniques, single port laparoscopic appendectomy has the advantages of feasibility without extensive endoscopic skills and an acceptable operative time. Technical refinements and accumulated experience probably will enable its wider use for more patients with acute appendicitis.

Clinical Analysis of Inguinal Hernia in Adult Using Prolene Hernia System

PURPOSE: The aim of this study was to detail clinical experiences with a type of tension-free herniorrhaphy using the prolene hernia system (PHS) and analyze the system's usefulness. METHODS: We retrospectively reviewed the medical records of 122 patients who underwent an inguinal hernia repair using PHS between March 2004 and August 2008. RESULTS: There were 116 male and 6 female patients ages 14 to 99; 79 indirect, 33 direct, 10 pantaloon hernias. The right inguinal hernias were more frequent (64.7%). The mean operative time for inguinal hernia repair using PHS was 45.2+/-1.5 minutes and the mean postoperative hospital stay was 3.5+/-1.5 days (101+/-82.9 hours). The most frequent combined disease was hypertension. The most frequent complication of PHS repair was hematoma. The mean number of used analgesics was 3.1+/-3.3. There were no postoperative recurrences. CONCLUSION: Tension-free herniorrhaphy using PHS is thought to be a useful method of inguinal hernia repair in adults because it offers lower postoperative pain, shorter operation time and shorter postoperative hospital stay.

Paraesophageal Hernia with Small Bowel Strangulation

Paraesophageal hernias are usually classified into three distinct types: type I, sliding hernias; type II, paraesophageal hernias; type III, a combination of type I and II. Herniation of other abdominal organs can be classified as type IV, and is a rare situation at the esophageal hiatus. We report herein a 73-year-old female patient who presented with epigastric pain and diagnosed as type IV paraesophageal hernia. Initial evaluation was focused on myocardial ischemia. There was no evidence of myocardial ischemia in the coronary angiography, but follow-up chest X-ray revealed air-fluid levels in the left mediastinum suggested hiatal hernia. On computed tomography, herniation and strangulation of proximal jejunum into the hemithorax via left diaphragmatic defect was found. After reduction of small bowel and resection of strangulated segment, the defect was closed. Fluid collection in the hernia sac was detected at postoperative day nine, but she was discharged without complication.

Pneumatosis Cystoides Intestinalis with Intestinal Volvulus

Pneumatosis cystoides intestinalis is an uncommon condition characterized by the presence of multiple gas-filled cysts within the wall of the gastrointestinal tract. It is still a poorly understood phenomenon, considered to result from primary mucosal insult from varying causes. However, it is associated with various diseases, including gastroenteral obstructive and connective vascular diseases and even pulmonary or endocrine diseases. Authors report a case of pneumatosis cystoides intestinalis with volvulus in the small intestine that developed in a 44-year-old man without history of any special underlying diseases.

Subclavian Steal Syndrome

The definition of subclavian steal is the reversal of vertebral blood flow resulting from the stenosis or occlusion of one of the subclavian arteries or the innominate artery. It is a rare disease resulting in a variety of ischemic neurologic symptoms such as vertigo, dizziness, diplopia, dysarthria, ataxia and nystagmus. Some patients show ischemic symptoms and digital necrosis of the involved arm. Among treatment options, Subclavian to carotid transposition is the most preferred method. We report a patient with subclavian steal syndrome who had 5th finger necrosis of the left hand without neurologic symptoms. It was successfully treated with a carotid-subclavian bypass with a 6 mm ePTFE graft.

Multilevel Duodenal Injury after Blunt Trauma

Duodenal trauma is an uncommon injury associated with significant mortality and morbidity. Upper gastrointestinal radiological studies and computed tomography may lead to the diagnosis of blunt duodenal trauma. Exploratory laparotomy remains as the ultimate diagnostic test if a high suspicion of duodenal injury continues even in the face of absent or equivocal radiographic signs. The majority of duodenal injuries may be managed by simple repair of the injured site. More complicated injuries require more sophisticated techniques. Here, we report a case of multilevel blunt duodenal injury successfully managed with duodenal diverticulization, Roux-en-Y gastrojejunostomy and catheter duodenostomy.

A Clinical Study of Traumatic Duodenal Injury

PURPOSE: Traumatic duodenal injury is rare. There is no consensus on what type of repair should be performed for duodenal perforations with respect to their varying severity. As a result, surgeons are confronted with the dilemma of choosing between several diagnostic tests and many surgical procedures. In this study, we report our experience with treating traumatic duodenal injury and also offer a review of the literature. METHODS: Seventeen patients with duodenal injury following abdominal trauma were treated by several methods between January 1992 and October 2006. Based on review of the medical records, we classified the patients as having grade I through V duodenal injury using the scale constructed by the American Association for the Surgery of Trauma (AAST). We also noted clinical features, operative management, and outcome. RESULTS: Among 17 patients, one patient who had a duodenal intramural hematoma was treated by conservative management. Seven patients were treated by duodenojejunostomy, with only one complication. The remaining 9 patients underwent various operations, including primary closure alone (n=3), primary closure with jejunal patch (n=1), primary closure with duodenostomy (n=3), and pancreaticoduodenectomy (n=2). The complication rate among patients who underwent surgery within 24 hours after injury was 1 case among 13. However, complications occurred in all 4 surgical cases undertaken more than 24 hours after injury. CONCLUSION: Early diagnosis (within 24 hours) and thorough inspection during exploration provide the best means toward reducing complications associated with traumatic duodenal injury.

A Clinical Study of Traumatic Duodenal Injury

PURPOSE: Traumatic duodenal injury is rare. There is no consensus on what type of repair should be performed for duodenal perforations with respect to their varying severity. As a result, surgeons are confronted with the dilemma of choosing between several diagnostic tests and many surgical procedures. In this study, we report our experience with treating traumatic duodenal injury and also offer a review of the literature. METHODS: Seventeen patients with duodenal injury following abdominal trauma were treated by several methods between January 1992 and October 2006. Based on review of the medical records, we classified the patients as having grade I through V duodenal injury using the scale constructed by the American Association for the Surgery of Trauma (AAST). We also noted clinical features, operative management, and outcome. RESULTS: Among 17 patients, one patient who had a duodenal intramural hematoma was treated by conservative management. Seven patients were treated by duodenojejunostomy, with only one complication. The remaining 9 patients underwent various operations, including primary closure alone (n=3), primary closure with jejunal patch (n=1), primary closure with duodenostomy (n=3), and pancreaticoduodenectomy (n=2). The complication rate among patients who underwent surgery within 24 hours after injury was 1 case among 13. However, complications occurred in all 4 surgical cases undertaken more than 24 hours after injury. CONCLUSION: Early diagnosis (within 24 hours) and thorough inspection during exploration provide the best means toward reducing complications associated with traumatic duodenal injury.

Hematological Features of Coagulopathy and the Efficacy of Antivenin Therapy for a Korean Snakebite

PURPOSE: Snake venom induced coagulopathy is a major cause of both morbidity and mortality among affected patients. The effects of venomous factors to coagulation cascade and fibrinolysis were verified by analyzing the hematological data and clinical features of envenomed patients, and the efficacy of blood products transfusion and antivenin against a Korean snakebite clarified. METHODS: A retrospective study was conducted on 57 patients, admitted to the Department of Surgery of Chuncheon Sacred Hospital, between July 2002 and October 2005. According to the guidelines for assessing the severity of North American envenomination, the patients were divided into three groups according to severity, and the clinical course, DIC profile and usages of blood products and antivenin then analyzed. RESULTS: Of the 15 patients in the severe group (26.3%), 9 (60.0%) developed severe coagulation abnormalities, similar to DIC. No substantial bleeding or thrombic event manifested. All the patients with initial hypofibrinogenemia (33.3%) and unmeasured PT/aPTT during the 2nd to 4th hospital days (46.7%) progressed to severe coagulopathy. On average, these patients received transfusions of 18.4 +/- 6.1 pints of FFP and 14.4 +/- 14.9 pints of platelet product. The average amounts of antivenin applied were 1.2 +/- 0.4, 1.7 +/- 0.5 and 2.8 +/- 0.8 vials for the Minimal, Moderate and Severe groups, respectively. There was no death due to a Korean snakebite during this period. CONCLUSION: Korean snake venom is assumed to be a complex mixture of anticoagulant, platelet active and fibrinolytic venom. The discrepancy between abnormal coagulopathy and the clinical course explains venom induced DIC-like syndrome. Hypofibrinogenemia is the most reasonable predictor of DIC-like syndrome. Abrupt prolongation of PT/aPTT during the 2nd to 4th hospital days must weigh against thrombocytopenia. An early antivenin injection, along with the proper use of blood products, could improve the clinical course of envenomed patients.

A Clinical and Hematological Analysis of the Traumatic Splenectomy

PURPOSE: The spleen is the organ most frequently injured by abdominal trauma; often by penetrating wounds to the left lower chest, flank and upper abdomen. A total splenectomy is considered the standard method of treating a splenic injury in the case of multiple organ injuries, a hemodynamically unstable condition and severe splenic injury. During the 5 years, between May 2001 and October 2005 55 splenectomy cases were performed at our clinic. This study was carried out to evaluate the clinical and hematological analysis of a splenectomy undertaken due to trauma (39 cases), with the exception of hematological diseases (16 cases). METHODS: We analyzed the clinical manifestations, intraabdominal blood loss, the total amount of transfusion, postoperative complications, and the distribution of platelet counts after a splenectomy, average time to reach maximal platelet counts and return normal platelet counts, and the periods of aspirin medication in 39 traumatic splenectomy cases. RESULTS: The male to female ratio was 2.3 : 1, with the most frequently injured age group being those in their third decade. The most common cause of injury was traffic accident (76.9%). There were 24 (61.5%) cases of associated injury, with the most frequents associated injury being a rib fracture (17 cases). The most common type of splenic injury was Type IV (59%). The average amount of intraabdominal blood loss and amount of transfused blood were 1,850 and 2,700 ml, respectively. The postoperative complication rate was 33.3% (13 cases), with pulmonary complications the most common (8 cases). Thrombocytosis occurred in 33 case 84.6%. After a splenectomy, the first increasing platelet count was noted after an average of 6.7+/-2.0 days, with the maximal count reached after an average of 10.8+/-2.8 days. The platelet count gradually returned to normal levels after an average of 36.1+/-20.0 days. Aspirin was medicated from a minimum of 9 to a maximum of 39 days, with an average of 23.3 days. CONCLUSION: Men in thier twenties were the most commonly injured group. Grade IV splenic injuries were the most common type requiring surgery. The average time to reach postoperative maximal platelet counts was 10.8 days. The patients where the platelet count increased above 750,000/ mm3 were treated with aspirin; there were no complications. Therefore, it is advisable to start patients on aspirin medication of aspirin, and follow up thier needs as out-patients with regular CBC workups.

An Ileal Duplication in a 12-year-old Girl which was Resected by Laparoscopy-assisted Surgery

Gastrointestinal duplication is a rare congenital anomaly which can occur anywhere along the digestive tract. The most common site is the mesenteric border of the terminal ileum. Intestinal duplication usually becomes symptomatic early in life with the severity of symptoms depending on the location and type of mucosal lining. Ectopic gastric mucosa is an associated possibility. Gastrointestinal hemorrhage is the most serious complication, which can cause severe anemia and shock. Another complication, although rare, is carcinoma in a duplicate cyst. We experienced an unusual case of a 12-years-old girl who presented with intermittent abdominal pain and hematochezia. There was no abnormality on Meckel's scan. Abdominal CT revealed a cystic mass in the pelvic cavity and subsequent transabdominal ultrasound showed the double-layered wall of the duplication. We performed laparoscopy-assisted, segmental resection of the ileum. The patient was discharged without any complication on the 7th postoperative day.

Iatrogenic or Traumatic Pseudoaneurysms of Peripheral Artery: 2 Cases Report

Pseudoaneurysm can occur as the result of penetrating trauma, infection and as the sequelae of radiologic intervention. Acupuncture is widely used in oriental countries such as China, Japan and Korea. In western countries acupuncture therapy is used to treat musculoskeletal symptoms such as sprain or strain. Some complications have been reported after acupuncture therapy. Vascular trauma after orthopedic surgery is relatively rare, but it is a significant complicaiton that increases the morbidity and mortality. We had experienced two different cases of pseudoaneurysms that occurred after acupuncture and orthopedic surgery respectively and the patients were treated successfully with interventional and surgical procedures.

Iatrogenic or Traumatic Pseudoaneurysms of Peripheral Artery: 2 Cases Report

Pseudoaneurysm can occur as the result of penetrating trauma, infection and as the sequelae of radiologic intervention. Acupuncture is widely used in oriental countries such as China, Japan and Korea. In western countries acupuncture therapy is used to treat musculoskeletal symptoms such as sprain or strain. Some complications have been reported after acupuncture therapy. Vascular trauma after orthopedic surgery is relatively rare, but it is a significant complicaiton that increases the morbidity and mortality. We had experienced two different cases of pseudoaneurysms that occurred after acupuncture and orthopedic surgery respectively and the patients were treated successfully with interventional and surgical procedures.

Morgagni Hernia

The cause of a congenital diaphragmatic hernia is unknown. However, it is believed to result from a failure of pleuroperitoneal canal closure in a developing embryo. Congenital herniation of the anteromedial, retrosternal diaphragm is known as Morgagni hernia. We experienced a case of Morgagni hernia in an eighty three-year-old female who was admitted complaining of right upper abdominal pain. The Morgagni hernia was found incidentally by abdominal CT, Chest PA and right lateral view during the work up. A reduction of the transverse colon and greater omentum, and a cholecystectomy were performed. The size of the opening was 5x6 cm. The patient was discharged without complications.