Single institution experience of single incision trans-umbilical laparoscopic cholecystectomy using conventional laparoscopic instruments.

BACKGROUND: Since the implement of laparoscopic cholecystectomy as the gold standard treatment for gall bladder stones, there has been a trend toward minimizing the required number and size of ports to reduce postoperative pain with better cosmetic results. We conducted this study to evaluate the feasibility, safety, advantages and complications of single incision laparoscopic cholecystectomy using the conventional laparoscopic instruments. METHODS AND PATIENTS: Eighty patients (68 females and 12 males) with uncomplicated symptomatic gall bladder stones underwent elective laparoscopic cholecystectomy via single trans-umbilical incision using the conventional laparoscopic instruments. RESULTS: The mean operative time was 61.75 min (range: 40-105 min) and the mean estimated blood loss was 17.21 ml (range: 5-90 ml). Gall bladder perforation occurred in five cases (6.25%) with calculi spillage in four of them. It was managed by using laparoscopic stone removal forceps. Troublesome cystic artery bleeding occurred in 2 cases (2.5%) while gall bladder bed bleeding happened in one case (1.25%) with liver cirrhosis and managed by argon beam coagulation. An intraoperative cholangiography was performed in 3 cases and a drain was inserted in one case. There was no conversion to the open technique in any of the cases. 49 patients (94.2%) discharged on the 1st postoperative day and 3 patients (5.8%) discharged on the 2nd postoperative day. The average wound length measured on 3rd postoperative month was 1.58 cm (range, 1.3-2.1 mm); while average score of patient satisfaction of the surgery was of 9.32 (range, 7-10). CONCLUSION: In uncomplicated gall bladder disease; single incision laparoscopic cholecystectomy is feasible and safe. It has an excellent esthetic results and high grade of patient satisfaction. It could be performed with the conventional laparoscopic instruments and its scale of application could be widened once enough experience attained.

A study of the effect of splenectomy on hepatic functional reserve and structural damage in patients with chronic hepatitis C virus infection by non-invasive serum markers. A prospective study.

Several beneficial effects of splenectomy on the liver integrity have been recently reported by both experimental and clinical studies. However, the effects of splenectomy on hepatic functional reserve and structural damage in patients with chronic hepatitis C (CHC) were not studied by objective evidence. The aim of this study was to assess the effect of splenectomy on hepatic functional reserve and structural damage in patients with CHC by non-invasive serum markers. The study involved 22 patients with histopathological diagnosis of CHC undergoing splenectomy for treatment of associated hypersplenism. The hepatic functional reserve and structural damage markers were assessed before and after splenectomy surgery on the 2nd and 60th postoperative days by aspartate aminotransferase to alanine aminotransferase (AST/ALT ratio), AST to platelet ratio index (APRI) and serum levels of gamma-glutamyl transferase (GGT), hyaluronic acid (HA), type IV collagen (CIV) and tissue inhibitor of metalloproteinase-1 (TIMP-1). After splenectomy, the levels of serum HA showed a significant decrease in relation to the preoperative values both in PO-1 (mean pre-splenectomy: 272+/-88.6 versus 185+/-77.4 ng/ml; P=0.01) and PO-2 (169+/-58.1 ng/ml; 0.017). The levels of type IV collagen showed a significant decrease in relation to the preoperative values both in PO-1 (mean pre-splenectomy: 208+/-134 versus 125+/-100 ng/ml; P=0.01) and PO-2 (121+/-74.7 ng/ml; P=0.02). Serum levels of TIMP-1 also showed a significant decrease in relation to the preoperative values both in PO-1 (mean pre-splenectomy: 764+/-571 versus 261+/-195 ng/ml; P=0.006) and PO-2 (149+/-110.1 ng/ml; P=0.004). There was no significant difference between PO-1 and PO-2 mean values for each of those serum markers. This study found that splenectomy induced a reduction of biochemical markers of liver functional reserve and fibrosis in patients with chronic hepatitis C which reflect a change in the processes involved in of liver fibrosis. However, it cannot be concluded whether this reflects a change in the rate of its progression or a prevention of further fibrosis.

Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study.

UNLABELLED: By Evidence Based Medicine (EBM) principles, several meta-analyses concluded that use of mesh is superior to the non-mesh operations in inguinal hernia surgery. Wound infection is a potential complication of all hernia repairs and deep-seated infection involving an inserted mesh may result in chronic groin sepsis. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is presumed to increase that risk of infection. AIM: Aim of the study is to compare the outcome of tension-free mesh repair to Bassini technique used to treat strangulated inguinal hernia. PATIENTS AND METHODS: In the period from May 2004 to December 2006, 54 patients were submitted to emergency operation because of strangulated inguinal hernia. The patients were randomized into two groups (27 patients in each group). Group A patients underwent open tension-free anterior repair utilizing a monofilament polypropylene mesh according to Lichtenstein "tension-free" technique, whereas group B patients underwent Bassini technique. Mesh hernioplasty was not attempted in patients with preoperative peritonitis, inflammatory hernia and for those in whom bowel resection was perfumed for ischemic necrosis caused by strangulated inguinal hernia and they were excluded from the study. Assessment of the primary outcome included surgical complications and hospital stay and secondary outcome was the recurrence of hernia. RESULTS: Postoperative complication rate did not differ significantly between the two groups. Postoperative hospital stay was also significantly longer in group B compared to group A (5+/-3.4 days versus 3+/-2.1 days, p<0.01). During the follow-up, (mean 22+/-6months), three patients had recurrence after Bassini operation (group B), but there was no recurrent hernia after mesh herniorrhaphy (group A) (0/27=0% versus 3/27=7, 11.1%, p<0.001). CONCLUSION: The use of Lichtenstein "tension-free" technique in emergency treatment of strangulated inguinal hernia is safe, effective with an acceptably low rate of postoperative complications and without recurrence.

Gastrointestinal stromal tumors (GISTs): clinical presentation, diagnosis, surgical treatment and its outcome.

This study included 13 selected patients treated by surgical excision for lesions that proved postoperatively to be gastrointestinal stromal tumors (GISTs) by histopathological and immunohistochemistry studies. The demographic, clinical and operative reports data were collected. Eight cases were gastric GISTs, four cases were small bowel GISTs (jejunum 1 & ileum, 3) and GIST of the sigmoid colon was in one patient. Eight cases presented at the emergency department due to hematemesis (3), gastrointestinal obstruction (3), bowel perforation (1) and severe bleeding per rectum (1). Three cases presented with a feeling of abdominal fullness and ill-defined palpable abdominal mass. Two cases were discovered incidentally during GIT endoscopy for dyspepsia. Diagnosis of GISTs was presumed on clinical basis and operative findings from gross morphological features. Complete resection (R0) was achieved for 12 tumors (92.3%). The immunohistochemistry profile was positive for C-kit for all cases. One operative death was due to massive pulmonary embolism. Postoperative complications occurred in three (23%) as upper GIT bleeding (1), biliary gastritis (1) and wound infection (1), and one (7.69%) of ileum tumor recurrence.

The effect of portal vein branch plus heterochronous hepatic artery branch ligation on liver regeneration (experimental study).

The proliferative capacity of non-ligated liver lobes was designned experimental study on dogs in which portal vein and hepatic artery ligation was done either simultaneously or heterochronously. Dogs were divided into four groups: G I (control G); laparotomy was performed without vascular ligation, G II; dogs were subjected to ligation of the right lateral and median branches of portal vein alone, G III, dogs were subjected to hepatic artery branches ligation 48h after portal vein branches ligation. G IV, dogs were subjected to ligation of the same branches of the portal vein and hepatic artery simultaneously. Dogs from each group were subjected to a liver biopsy before and 24, 48, 72, & 168h (one week) after surgery. Standard serum liver functions were tested before ligation, 72 hs and one week after ligation. Hepatic regeneration in the non-ligated lobe was assessed through histo-pathological study, DNA quantitation of the hepatic nuclei by the computerized image analysis system and estimation of proliferation marker in hepatic tissue. In this study, the labeling index of the nuclear factor NF Kappa B (P105), a novel monoclonal antibody specific for P105 protein, was determined immunohistochemically. Results showed induction of the NK kappa B (P105) labeling index showed maximum levels G III. Quantitative determination of serum glutamic-oxalacetate transaminase (GOT) showed peak levels in G IV at 24h after surgery. Our finding for this index that heterochronous partial portal vein and hepatic artery ligation (i.e., G III) is effective, because this procedure leads to an increase in the compensatory hypertrophy of the non-ligated liver lobes that depends on the regenerative capacity of the lobes themselves. In contrast, in G IV (i.e., synchronous ligation of portal vein and hepatic artery branches) liver regeneration did not occur due to the severe systemic damage induced by infectious necrosis in the ligated lobe. The serial changes in liver function in G III indicate that the use of this technique may minimize dysfunction in the remaining hypertrophied liver lobes, similar to findings in G II. So, the PVBL plus heterochronous HABL procedure is safer and more effective than PVBL alone, or PVBL plus simultaneous HABL. A better knowledge of the events following such heterochronous ligation should improve the clinical outcome of hepatic resection for liver diseases.

A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy.

BACKGROUND: Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique. However, it may be associated with coexisting occult sphincter defects. Whether continence is related to the extent of sphincterotomy remains debatable. The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division. METHODS: One hundred eight patients with chronic anal fissure were prospectively studied before and after lateral internal sphincterotomy. A questionnaire was completed for each patient before and after surgery with regard to any degree of fecal incontinence. Fecal incontinence severity index was assessed using the Cleveland Clinic Incontinence Score. The patients with preoperative perfect continence were randomized into two groups (46 patients in each group): Group 1 underwent traditional lateral internal sphincterotomy (up to the dentate line) and Group 2 were underwent a conservative internal anal sphincterotomy (up to the height of the fissure apex or just below it). RESULTS: Minor degrees of incontinence were present before surgery in 16 patients (14.8%). Results of the randomized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients (6.52 %) who did not have it before surgery. Five of the six (10.86%) were in Group 1 one (2.17%) was in Group 2 (p = 0.039). Persistent incontinence occurred in two in Group 1 (4.35%). All of them were females. All have had a history of one or more vaginal deliveries. CONCLUSION: A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy. Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon. Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing, but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex. Care should be exercised in female patients with a history of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.

Combined low pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy.

INTRODUCTION: Intraabdominal CO(2) gas after laparoscopic cholecystectomy causes postoperative shoulder-tip pain. Many methods of analgesia have been used to reduce this pain, including analgesic drugs, intraperitoneal local anesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas, and nitrous oxide pneumoperitoneum. The aim of this study was to evaluate the efficacy of combined low-pressure CO(2) pneumoperitoneum and intraperitoneal infusion of normal saline in reducing the incidence of postoperative shoulder-tip pain. METHODS: Altogether, 109 patients undergoing elective laparoscopic cholecystectomy were randomized prospectively into three groups. Patients in group A (n = 34) underwent laparoscopic cholecystectomy with 14 mmHg CO(2) pneumoperitoneum; patients in group B (n = 37) underwent laparoscopic cholecystectomy with 10 mmHg CO(2) pneumoperitoneum; and those in group C (n = 38) underwent laparoscopic cholecystectomy with 10 mmHg CO(2) pneumoperitoneum in addition to intraperitoneal normal saline infusion in the right hemidiaphragmatic area. Shoulder-tip pain was recorded on a verbal rating scale 2, 6, 12, 24, and 48 hours after operation. RESULTS: Twelve patients in group A (35.2 percent), six in group B (16.2 percent), and seven in group C (18.4 percent) complained of shoulder-tip pain. Hence, there was a significant decrease in the frequency of shoulder-tip pain in groups B and C in relation to group A, but there was no significant difference between groups B and C. The postoperative shoulder-tip pain scores were significantly reduced in group C at 6, 12, and 24 hours. The number of patients who required additional analgesics was also reduced in group C. CONCLUSIONS: Low-pressure CO(2) pneumoperitoneum reduces the number of patients complaining of shoulder-tip pain and the intensity of the pain after laparoscopic cholecystectomy. The addition of intraperitoneal normal saline infusion to low-pressure CO(2) pneumoperitoneum seems to reduce the intensity but not the frequency of shoulder-tip pain after laparoscopic cholecystectomy.

New approach in surgical management of complicated umbilical hernia in the cirrhotic patient with ascites.

A total of 23 consecutive patients operated upon on emergency basis for the treatment of complicated umbilical hernias associated with liver cirrhosis and ascites. The hernia was complicated by strangulation in 11 and ascitic fluid leak in twelve of the patients. Patients were assigned randomly in two groups. In the first group (GI, n = 12) peritoneal drainage at the conclusion of their surgery was done but no drainage was applied in the second group (GII, n=12). All patients were operated upon and when closed system peritoneal drainage was done, it was brought to outside of the abdomen through a separate stab. No negative pressure was applied. The main outcome measures were postoperative wound healing, control of ascites, complications, and hernia recurrence rate at follow up. The male/female ratio, Child's class, ascites severity, and mode of hernia complication were almost matched in both groups. Postoperative wound dehiscence occurred in four patients in G II (23.5%) but in none of GI. Control of ascites was achieved in all patients of GI. The overall mean hospital stay was significantly lower in-patient of GI than those of the G II (P < 0.0 1). Recurrences of the hernia occurred in one patient only of the G I and in three of the G II on a mean follow- up of 19+/-3 months. So, postoperative closed peritoneal drainage in the management of complicated umbilical hernias associated with liver cirrhosis and ascites safe and effective in assuring postoperative wound healing, control of ascites and the prevention of hernia recurrence. It is specifically indicated in cases with bowel resection anastomosis and in patients with low preoperative serum albumin and history of rapid ascites re-accumulation under medical therapy.