Synchronous Cholecystectomy and Totally Extraperitoneal (TEP) Herniorrhaphy Using an Umbilical Incision

Two or more procedures maybe combined into a single surgical event using an abdominal laparoscopic surgery technique. Synchronous operations can provide patients with the advantage of a single hospital stay, single anesthetic exposure and single recovery period. Cholecystectomy and totally extraperitoneal (TEP) herniorrhaphy should be performed in both extremities and in different spaces of the abdomen. As described in this report, laparoendoscopic single site surgery (LESS), synchronous cholecystectomy and TEP herniorrhaphy were successfully performed using an umbilical incision in a single surgical event.

Efficacy of Ligasure(TM) in a Hemorrhoidectomy: Comparison with Semi-open Hemorrhoidectomy

PURPOSE: Ligasure(TM) is a feedback-controlled bipolar diathermy originally devised to seal vessels and developed to weld tissue bundles. The tissue fusion mechanism consists of melting collagen and elastin, and the tissue welding property of Ligasure(TM) can be used in a hemorrhoidectomy. To confirm the efficacy of Ligasure(TM) in hemorrhoidectomies, I compared it with the conventional semi-open method. METHODS: One hundred patients with grade III or IV hemorrhoids were randomly assigned to the Ligasure(TM) (n=50) or the conventional semi-open (n=50) hemorrhoidectomy group. The operation time, the postoperative analgesic requirement, the hospital stay, the time to return to normal life, and complications were prospectively recorded and analyzed. RESULTS: There was no difference in sex and age between the two groups. The operation time was markedly shorter in the Ligasure(TM) group than semi-open group (10.8+/-4.0 versus 23.7+/-5.2 min; P<0.001). Although the hospital stay was not statistically different, the time to return to the normal life was shorter in the Ligasure(TM) group (9.5+/-3.8 versus 12.7+/-4.0 days; P<0.05). The requirement for postoperative analgesics within 48 hours (nalbuphine, 5mg) was not significantly different. In each group, an urinary retention was noted and treated with urinary catheterization. In Ligasure(TM) group, an anal stenosis was developed and was successfully treated with advancement flap surgery. In each group a secondary bleeding and a skin tag were noted. There was no wound infection or incontinence. CONCLUSIONS: Ligasure(TM) hemorrhoidectomy reduces the operation time and the time to return to the normal life. If anal stenosis is to be prevented, careful attention is required to preserve the anal skin and mucosa. Ligasure(TM) is simple to use and is useful in the treatment of patients with grade III or IV hemorrhoids.

Laparoscopic Cholecystectomy and ERCP with Sphincterotomy in a Woman with Situs Inversus Totalis

Situs inversus totalis is a mirror image of the normal anatomy in the thoracic and the abdominal cavity. The cardiac apex, the stomach and the aortic arch are all on the right side. It is a rare condition with a genetic predisposition that is autosomal recessive and is associated with a 5-10% incidence of congenital heart disease. In a situs inversus totalis with cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy was performed three days after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. In the laparoscopic cholecystectomy, pneumoperitoneum was made by a closed method, and the cholecystectomy was performed using the three trocar technique. Although we should pay much attention to the details of left-right reversal, these techniques can be safely and effectively applied to situs inversus totalis patients.

Surgical Treatment of Esophageal Perforation Caused by Balloon Catheter and Expandible Metal Stent in a Benign Distal Esophageal Stricture

An esophageal perforation is a condition requiring emergency treatment. Although previously spontaneous ruptures were the most common etiology, as endoscopic and radiologic diagnosis and treatment have developed recently, iatrogenic ruptures due to instrumentation have increased to become the most common cause of esophageal perforations. Generally, the treatment of esophageal stenosis is composed of esophageal dilatation using a Maloney or a Mercury dilator and medical treatment for reflux esophagitis. Recently, balloon-catheter dilatation of the esophagus has produced safe and excellent results, and self-expansible metallic stents has been very useful in controlling malignant strictures of the esophagus with low mortality and morbidity. We experienced an esophageal perforation after balloon dilatation and the insertion of a self-expanding silicone-covered Gianturco stent to the site of the esophageal stenosis which was due to reflux esophagitis. The abdomen was opened through an upper midline incision. There was a 3-cm-long longitudinal laceration on the distal esophagus which was closed transversely as with a Heinecke-Mikulicz pyloroplasty after a debridement. To reinforce the site of esophageal laceration and to prevent esophageal reflux, the gastric fundus was pulled and sutured over the esophageal sutures, and the second-layer mattress suture was made 1 cm proximal to the first sutures, including central ligaments of the diaphragm. To prevent bile reflux, we converted from a Billroth-II to a Roux- en-Y gastrojejunostomy. We followed up for 30 months and found no signs of any esophageal stenosis or gastroesophageal reflux.

Expression of Cellular Oncogenes in Colorectal Cancer : c-myc, c-Ha-ras and c-erbB-2

Although causative factors are not completely defined, carcinogenesis of colorectal cancer is attributed to multiple genetic alterations. The abnormal expressions of oncogenes are regarded to be responsible for the production of malignant phenotype, subsequent invasion and metastasis. From 63 surgically resectable colorectal adenocarcinoma patients, expression of oncogenes in colorectal cancer tissue was evaluated with immunohistochemical staining methods using monoclonal antibodies to products of the oncogenes. To evaluate the possibility of oncogenes as a prognostic factor, we studied the relationship between the expression of oncogenes and the clinicopathologic findings which are well known prognostic factors. Rates of expression in colorectal cancer tissue were 27% for c-myc, 74.6% for c-Ha-ras and 77.8% for c-erbB-2 oncogenes. The positive rate of c-erbB-2 oncogene was higher in the well differentiated group than in the poorly differentiated group. The rates of expression of c-myc and c-Ha-ras oncogenes were significantly correlated each other. Expression of these oncogenes in colorectal cancer were not correlated with the pathologic stage, location of cancer, DNA ploidy pattern and histologic differentiation except between c-erbB-2 and histologic differentiation. In conclusion, there seems to be a possibility that c-erbB-2 could be used as a prognostic factor of colorectal cancer. However, further and more intensive study seems to be required.

Mesenchymal Cell Tumors of the Gastrointestinal Tract

Mesenchymal cell tumors of the intestinal tract originate from connective tissues, muscles, fat, lymphatic tissues, blood vessels, and nerves in and beneath the submucosa. The most common site is the stomach, followed by the small bowel. Among the benign gastric neoplasms of mesodermal origin, those derived from smooth muscles constitute over 90%. Leiomyosarcomas of the stomach represent about 1% to 3% of primary malignant tumors and approximately 20% of submucosal tumors of the stomach. In the small bowel, leiomyoma is the most common benign tumor, and leiomyosarcoma represents about 19% of malignant tumors. The principle of surgical treatment of gastric mesenchymal tumors is local excision with a 2 to 3 cm margin in the surrounding gastric wall. We reviewed 48 cases of mesenchymal cell tumors of the gastrointestinal tract from January 1988 to March 1997 at the Department of Surgery, Namkwang General Hospital and Chonnam University Hospital School. The results are as follows : 1) There were 23 benign and 25 malignant tumors. 2) The most common benign tumor was leiomyoma (41.7%) and the most common malignant tumor was a leiomyosarcoma (47.9%). 3) The most common site was the stomach (52.1%), followed by the small bowel (25%); in the gastric tumor cases, the most common site was the body (60%). 4) The most common clinical manifestation was abdominal pain (37.5%), followed by bleeding (27.1%), a palpable mass, dyspepsia, and weight loss. 5) A wedge resection, a subtotal gastrectomy, or an enucleation of the mass was mainly performed on the stomach. Segmental resection and anastomosis was primarily performed in the small bowel. 6) Among the malignant tumors, a recurrence was noted in 8 patients(32%) : 7 leiomyosarcomas and 1 malignant histiocytoma. 7) The prognosis for a malignant leiomyosarcoma was better than that for an adenocarcinoma and was associated with tumor size and histologic grade (mitosis/10 HFP). However, we could not find any correlation between the prognosis and lymph node metastasis.

Diagnostic Laparoscopy through a Right Lower Abdominal Incision in Suspected

Recently, diagnostic laparoscopy has proved useful in reproductive women and patients with suspicious appendicitis. Diagnostic laparoscopy is usually performed through an incision just above or below the umbilicus. But the periumbilical incision of laparoscopy sometimes causes unnecessary skin incision when converted to open conventional appendicectomy and incisional hernia through the periumbilical port site. To prevent these disadvantages I have performed diagnostic laparoscopy through a right lower abdominal incision in suspected appendicitis. A transverse skin incision of 1.5~2.0 cm in length is made in the right lower abdomen. Using the open method, a cannula is inserted into the peritoneal cavity. After establishing the pneumoperitoneum, the whole peritoneal cavity can be carefully observed by tilting the operation table. According to the laparoscopic findings, appendicectomy and/or other operations may be performed with the laparoscopic or conventional method. I have used this technique in 39 patients (17 men and 22 women; age range 6 to 69 years). Pathologic findings of removed appendices were 2 normal; 17 catarrhal; 13 suppurative; and 7 gangrenous. The appendix was not visualized in 4 patients; but, were diagnosed to be appendicitis according to the findings of neighboring structures. There was a false negative which was a focal appendicitis accompanied with salphingitis. But there was no false positive. Associated diseases were gall stone (3 cases), uterine myoma (2 cases), an inguinal hernia, an intestinal adhesion, an ulcerative colitis, and a Crohn's disease. In conclusion, this technique can be an alternative route when the periumbilical route is difficult to approach due to previous incisional scars. Compared to periumbilical laparoscopy: (1) it is technically easier because it is familiar to the general surgeon; (2) it is more effective for esthetic purposes because it does not leave an unnecessary skin incision; and (3) it can prevent incisional hemia.

Colorectal injury by compressed air: a report of 2 cases

We report two colorectal trauma patients whose rectosigmoid region was ruptured due to a jet of compressed air directed to their anus while they were playing practical jokes with their colleagues in their place of work. It was difficult to diagnose in one patient due to vague symptoms and signs and due to being stunned by a stroke of the compressed air. Both patients suffered from abdominal pain and distension, tension pneumoperitoneum and mild respiratory alkalosis. One patient was treated with primary two layer closure, and the other with primary two layer closure and sigmoid loop colostomy. Anorectal manometry and transanal ultrasonography checked 4 weeks after surgery, revealed normal anorectal function and anatomy. The postoperative courses were favorable without any wound infection or intraabdominal sepsis.