Transmesenteriális colon átvezetéses colorectális anasztomózis.

Introduction: A crucial element of colorectal surgery is ensuring a safe anastomosis. In order to avoid the most significant complication - anastomotic leakage - two factors are essential: adequate blood supply and a tension-free suture. After extended resections, the mobilised colon sometimes cannot be connected to the rectal stump without tension. In these cases, transmesenteric placement of the transverse colon may facilitate a tension free anastomosis. Methods: The results of transmesenteric colorectal anastomoses performed at the Surgical Department of the BAZ County Central Hospital and University Teaching Hospital are reviewed and compared with literature data. Results: Eight patients underwent transmesenteric colorectal anastomosis. No anastomotic insufficiency was observed. Intra-operative blood loss, postoperative intestinal passage induction were similar to those expected with conventional anastomosis. Six cases were completed by laparoscopy, two by laparotomy, and two patients have been converted after laparoscopy. Conclusion: Extended left sided colorectal resections may result in inadequate residual bowel length, which could compromise the anastomosis. When the mobilised left colon does not reach the rectum without tension, transmesenterically placed transverse colon can be used. This surgical technique, which can also be performed laparoscopically, represents a safe alternative of achieving a tension-free anastomosis.

[The comparison of open and laparoscopic surgeries of the locally advanced chemo-irradiated rectum tumours]. / Lokálisan elorehaladott kemoirradiált rectumtumorok nyitott és laparoszkópos mutéteinek az összehasonlítása.

Introduction: The raison d'etre of laparoscopic surgery of colonic tumours is supported by many I/a level evidence. There are a lot of excellent early and late results regarding sigmoid and upper third rectum tumours in favour of laparoscopic surgery. There are not many literature proposals like this regarding chemo-irradiated tumours. Material and method: One hundred ninety-six patients received neoadjuvant treatment due to lower and middle third rectum tumours in the Borsod-Abaúj-Zemplén County Hospital between the 1st of January 2006 and the 31st of December 2011. Twelve patients out the 196 were not followed up, so we analysed 184 patients' data. We performed laparoscopic surgery on 67 patients. Conversion happened on 15 patients out of the 67 cases. Open surgery was performed on 117 patients. We strived for the ligation of the inferior mesenteric artery at the origin, the sparing of the autonomic nerves and the precise implementation of TME. The splenic flexure has been taken down during the operations that involved resection. Results: The Dukes stages as well as the, ASA stages were similar in both groups. There was no significant difference in the patients' BMI either. The length of the removed specimens and the tumour size were similar too. The defining factors of recurrence are the involvement of the circumferential resection margin (CRM) and the complete execution of the TME. These were appropriate in our laparoscopic cases, and we did not find a significant difference in between the groups (Chi-square test, p = 0.94). The operation time was similar in the laparoscopic, converted and open surgeries, and there was no significant difference either. The shortest postoperative care time was in the laparoscopic group, but the Mann-Whitney test did not reveal a significant difference. Similarly to literature data, we experienced much less wound-related complications like infections and fever in the laparoscopic group. There was a significant difference in terms of transfusion demand comparing the laparoscopic and open operation groups, to the detriment of the open surgery group (Chi-square test, p = 0.04). We did not find a significant difference in recurrence or survival during follow-up of the patients. Conclusion: In addition to the short-term advantages of laparoscopic surgery, it is a safe procedure for the chemo-irradiated rectum tumours even from an oncological point of view. Both open and laparoscopic surgery requires high-level competency and qualification and these must be performed in centres.

[Laparoscopic cecal wedge resection]. / Laparoszkópos coecumkúp-reszekciók.

INTRODUCTION: Several indications of cecal wedge resection can be found in the literature, but the most common ones are acute appendicitis, appendiceal mucocele and selected cecal polyps. PURPOSE: We summarize the indications, review the results of laparoscopic cecal wedge resections carried out in our department from 01.01.2010 till 31.12.2016. A case report is presented when cecal resection was carried out for a cecal polyp. PATIENTS: Between 01.01.2010 and 31.12.2016, 56 patients underwent a laparoscopic cecal wedge resection. The mean age was 42 years (14-83), 28 males and 28 females. In 46 cases, the indication was complicated acute appendicitis, in 6 cases appendiceal mucocele, in the case of four patients endoscopically unresectable benign cecal polyps. RESULTS: The average operating time was 65 minutes. For the procedure we used two 10 mm and one 5 mm port, the resection was performed by using 45 or 60 mm laparoscopic stapler. In 57.1% of the reviewed cases, abdominal drainage was applied. Conversion was necessary in the case of 3 patients (5.4%), once due to bleeding, twice due to technical problems. Surgical complications occured in 4 patients (7.1%), all of them from the complicated appendicitis group: one of grade I by Clavien-Dindo, 3 of grade III. The reoperation rate was 5.4% (3 patients): reoperation was accounted for an abdominal wall phlegmon, a pericecal abscess, and once the suspicion of abdominal abscess which was not verified. Perioperative death did not occur.

[Outcomes following rectal and recto-sigmoid cancer resections: comparison of the laparoscopic and open techniques]. / Rectum- és rectosigmoidealis tumorresectiók eredményei: a laparoscopos és nyitott technika összehasonlítása.

BACKGROUND/AIMS: Surgical technique and experience are considered as significant determinants of the successful treatment of recto-sigmoid malignancies. METHODS: Two hundred patients operated on between 2005 and 2009 were prospectively followed with an average of 39.8 months. Patients with rectosigmoid or rectal cancer were included, either with primary resection or resection after neoadjuvant therapy. The primary aim was to assess the average survival in the two groups; secondary outcomes were stage specific survival and the incidence of loco-regional recurrence and distant metastases. Intra- and postoperative complications, operating time, onco-pathological specimen quality and length of stay were also analysed. RESULTS: During the follow-up comparable rates for 3-year survival and recurrence rates were found without statistical difference. Hospital stay in the laparoscopic group was significantly shorter and the mid-term survival rates were also better in the more advanced stages. Incisional hernia rate was significantly lower in the laparoscopic group. CONCLUSIONS: The results of laparoscopic rectal and recto-sigmoid resections were not inferior, and - in some aspects - they were even better compared to open procedures. Adding the properties of the minimally invasive technique (shorter recovery, reduced surgical stress reaction) this should be the preferred method of operative approach.

[Laparoscopic sigmoid resection in total situs inversus]. / Laparoscopos sigmaresectio situs inversus totalisban.

Total situs inversus (SIT) is a rare congenital disorder in which all abdominal and thoracic organs are in reversed position. A 57-year-old man with SIT presented with change in bowel habits and rectal bleeding.Colonoscopy and abdomino-pelvic CT scan confirmed a constricting sigmoid lesion with normal tumor-marker levels. In our department the elective laparoscopic colon resection with lymphadenectomy is the preferred alternative of open surgery and is the chosen method in about 60 percent of cases. This is the first documented case report in Hungarian of a laparoscopically resected sigmoid tumour in a patient with SIT. We believe that with appropriate knowledge of anatomy and advanced routine in laparoscopic surgery laparoscopic resection can be a safe method even in a special case like this one was.

Impact of positive intraabdominal lavage cytology on the long-term prognosis of colorectal cancer patients.

BACKGROUND: Our aim was to investigate the presence of free cancer cells found in lavage cytology specimens taken from the proximity of tumors during the course of curative open and laparoscopic colorectal resections and then examine and compare the long-term disease outcomes in cases of negative and positive cytology. Based on the results, we were hoping to identify the place of peritumoral lavage cytology among prognostic factors for disease recurrence. METHODS: Between January 1, 2005 and December 31, 2007 intraoperative peritoneal lavage cytology was performed in 145 patients who underwent curative colorectal procedures. In all, 37 of the procedures were laparoscopic resections. RESULTS: Malignant cells were detected in the intraoperative peritoneal lavage cytology samples from 25 patients. Median follow-up was 47 months (3-81 months). Among the 25 patients with positive cytology; locoregional recurrence or distant metastasis was found in 14 during this period (56 %), whereas among the 120 patients with negative cytology the incidence was 28 (23 %). CONCLUSIONS: The impact of tumor stage, lymph node status, and peritoneal lavage cytology on recurrence rates is significant. Tumor, nodal, and lavage cytology status can be organized hierarchically in relation to time of recurrence. Cytology is most important, with positivity rendering long-term prognosis unfavorable. When comparing surgical techniques (open versus laparoscopic), we found no significant difference in recurrence rates. Our study has shown that conventional peritoneal lavage cytology is a prognostic factor in the case of patients undergoing curative colorectal operations.

[Laparoscopic repair of abdominal wall hernias]. / Hasfali sérvek laparoscopos mutéti technikája.

Repair of abdominal wall defects is a challenge for all general surgeons and a variety of methods have been described in the past. Traditionally, primary suture repair was shown to have a high recurrence rate in long-term follow-up studies. Herniorrhaphies that apply a large prosthetic mesh are appear to have a lower failure rate, but extensive dissection of soft tissue contributes to an increased incidence of wound infections and wound-related complications. The method of laparoscopic incisional hernia repair was developed in the early 1990s. This technique is based on the same physical and surgical principles as the open underlay procedure. The laparoscopic intraperitoneal onlay mesh (IPOM) technique and mesh materials were developed further in subsequent years, and there have been numerous reports on successful use of the IPOM technique even for extremely large hernia openings in obese and elderly patients. Reduced surgical trauma and lower infection and recurrence rates are key advantages of the minimally invasive repair. Therefore, this operation has increased in popularity promising shorter hospital stay, improved outcome, and fewer complications than traditional open procedures.

[Laparoscopic treatment of appendiceal mucocele]. / Appendix mucokele laparoscopes mûtéti megoldása.

Mucocele is a mucin-filled cavity, which can be multi-loculated as well. Mucocele is relatively rarely found in the appendix. The disease does not cause any symptoms in most cases, and it is usually an accidental finding. A thorough investigation should be carried out to exclude malignancy. Depending on the operative findings and the full histological report, the spectrum of surgery extends from appendectomy to right hemicolectomy. In this paper, we discuss the presentation, diagnostical options, and the possible surgical treatment--based on our experience with five cases. In three cases a non-tender mass was palpable in the right lower quadrant of the abdomen, while another patient presented with right lower quadrant abdominal pain and one with abdominal pain and diarrhoea. Abdominal and pelvic ultrasound and CT scans raised the possibility of mucocele, however colonoscopy was negative. After laparoscopic exploration, laparoscopy assisted partial caecum resection was carried out in two cases, in further two cases laparoscopic appendectomy, and in one case laparoscopic partial caecum resection was done. The hystological examinations showed appendiceal mucocele with no malignancy demonstrated. All patients recovered without complications, they were discharged from hospital on postoperative day five. The patients have been disease free after a 6-30 month follow-up period. We concluded that laparoscopy is a recommended method for the surgery of appendiceal mucocele.

[Laparoscopic reconstruction of abdominal wall hernias]. / Hasfali sérvek laparoscopos rekonstrukciója.

The widespread use of tension free surgical techniques and the modern, tissue-friendly surgical meshes have led to the development of new surgical techniques. The increasing importance of minimal invasive surgery became apparent in abdominal wall reconstructions, too, and their use has been justified by literature data. This procedure combines the advantages of minimal invasive surgery with tension free technique. The authors discuss 102 patients operated with abdominal wall hernias using a laparoscopic technique. There were 978 abdominal wall hernia operations in our department between 1 January 1999 and 31 December 2006, of which 102 cases were done laparoscopically. The average size of the abdominal wall defects was 62 square cm (minimum size: 12, maximum size: 160). The average size of the implanted surgical mesh was 300 square cm (min size: 150, max size: 750). Operating time was between 30 and 180 minutes. (The average time was exactly 70 minutes.) The hospital stay was between 1 to 7 days (4 days on average). Two recurrences were observed during the follow-up so far. The follow-up was from 2 to 96 months, with an average of 18 months. The laparoscopic technique significantly decreased the complication and recurrence rate, and shortened hospital stay compared to open surgery. Furthermore, laparoscopic technique improves aesthetic outcome, too. In addition, the authors found that small, hidden incisional hernia orifices could be explored and closed more easily with laparoscopic hernia repair.

[Laparoscopic choledocho-duodenostomy]. / Laparoszkópos choledocho-duodenostomia.

It is widely accepted today, that laparoscopic exploration of the common bile duct is an effective method for the treatment of obstructive jaundice, when it is caused by ductal calculi. In case of periampullary lesions, endoscopic stenting or surgical biliodigestive diversion might be the treatment of choice when radical solution is impossible or not necessary. The latter is still performed by laparotomy in a large number of cases due to technical challenges of the biliodigestive anastomosis in the laparoscopic approach. The authors present the case of a 76 year old patient with poor general condition, obstructive jaundice and signs of biliary calculosis by ultrasound. Attempt to its endoscopic verification and treatment has failed, due to lack of cooperation. Laparoscopic common bile duct exploration was performed which has revealed small ductal calculi and stricture of the papilla. After extraction of ductal calculi, hand sutured, side to side choledocho-duodenostomy was performed laparoscopically to achieve permanent biliary diversion. The anastomosis was prepared with absorbable, monolayer, interrupted sutures. The postoperative course was uneventful During regular follow up no complications have been observed. The authors conclude, that in selected cases, choledocho-duodenostomy might be constructed safely laparoscopically, too. This procedure is especially advantageous for elderly patients and for patients in poor condition.

[Laparoscopic colon operations for endoscopically unremovable polyps and tumors]. / Laparoszkópos vastagbélmuitétek endoszkóposan nem eltávolítható polip és daganat miatt.

The use of laparoscopy in colorectal surgery is expanding. Minimally invasive surgery of benign lesions is widely accepted and can be performed with good results even during the learning curve. After gaining adequate expertise one can remove polyps which can not be treated with a colonoscope and early colonic carcinomas. We performed 16 laparoscopic resections for colon polyps and early carcinomas between December 2002 and March 2005. On one occasion a benign polyp was removed through mini laparotomy after colotomy; 13 resections and 2 subtotal colectomies were performed. One conversion due to intraoperative bleeding and one reoperation for anastomotic leak was necessary. One patient died after late postoperative mesenteric artery occlusion but if there was no complication definite advantages of the minimally invasive technique were observed. The laparoscopic approach can safely be used in selected patients. After training in the standard surgical procedure one can proceed to more radical surgery in adequately controlled studies.

[Laparoscopic rectocele repair with mesh--a case report]. / Rectokele laparoszkópos megoldása muanyag háló beültetésével--esetismertetés.

Relaxation of the pelvic floor causes changes in the anatomy. This results in symptoms, which can be treated with different operations. The use of modern, minimal invasive methods and tension free mesh implants for the reconstruction is widely used in rectocele repair as well. We present a 59 year-old patient undergone both vaginal hysterectomy and cystocele repair previously who complained of progressive constipation. Physical examination and dynamic defecography confirmed the presence of a significant rectocele. Anal manometry showed no functional loss. Mobilisation of the rectum and division of the recto-vaginal septum was performed laparoscopically followed by rectopexy and reinforcement of the septum by fixing polypropylene mesh in each position. There was no complication and recovery was fast. Control defecography and functional test one month later did not show pathological findings. One year after surgery the patient is free of complaints or recurrence. In selected patients both laparoscopic approach and mesh implants are safe.

[Lichtenstein's hernioplasty]. / Lichtenstein mutéteinkrol.

In recent years in Hungary similarly to the worldwide trend the treatment of inguinal hernias has changed. New tension-free methods were developed and--after the introduction by the Department of Surgery, Medical Faculty, University of Pécs--Lichtenstein's method is widely used. Lichtenstein's method has become the gold standard at our department because of its highly favourable results: simple technique, minimal postoperative pain, recurrence rate below 1%, short hospital stay, very low complication rate and early return to physical activity.

[Laparoscopic exploration of the common bile duct]. / A közös epevezeték laparoszkópos feltárása.

Since the first laparoscopic common bile duct exploration in Hungary published in 1999 the authors use the technique themselves. We review and analyse our activity between 1 June 1999 and 31 August 2003. The minimally invasive approach was selected in twelve patients with obstructive jaundice for suspected bile duct stones. Eight of these patients underwent preoperative endoscopy, but either the number and/or size of stones or various complications prevented successful endoscopic stone extraction; five sphincterotomies--two followed by stenting--were performed. The four other patients did not consent to endoscopy. During surgery the biliary tract was visualised by choledochoscope (a bile duct endoscope with video connection) in four cases via the distended cystic duct and in eight cases via longitudinal choledochotomy. In one case there was no occlusion at all, in another one dilatation was performed because of a structure. In nine patients stones were removed either through the choledochotomy/cystic duct or by passing them into the duodenum. In one patient we converted to open procedure due to a stone impacted in the papilla of Vater. After choledochotomy intracorporal suturing and knot tying techniques were used to close the incision. On six occasions a cystic drain, three occasions a T-tube and on three occasions primary closure was used. Two bile leaks were treated by endoscopic stenting and in one patient a laparotomy was needed. There was no mortality. We believe that laparoscopic common bile duct exploration can be successful even in complicated situations.