Laparoscopic excision of a single hepatic hydatid cyst.

Many reports have recently shown the feasibility of treating simple cysts, polycystic disease of the liver and biliary cysts by laparoscopy. Groups having experience in this kind of surgery stressed the contraindication to manage hydatid cysts of the liver laparoscopically. This reflects the primary concern regarding the possibility of cyst content spillage. This presentation aims to demonstrate the feasibility and safety of laparoscopic treatment of special types of hepatic hydatid cysts. A 26-year-old female Yemeni patient presented with atypical gall bladder dyspepsia. Abdominal ultrasound only showed chronic calcular cholecystitis. The patient was scheduled for laparoscopic cholecystectomy on the 18th of August 1992. On exploration a globular cyst about 12 cm hanging with a stalk from the under surface of the right lobe of the liver was noticed. The gall bladder was used to elevate the liver. Dissection of the mass from the surrounding structures was achieved. Puncture and suction of the germinal and laminated layers were done. The connecting stalk was doubly ligated with endoloops and cut in between. The patient made an uneventful recovery and was discharged 48 hours later. Hydatid cysts of the liver are dangerous to handle by laparoscopy. However whenever a case is met with where excision can be done, this could be achieved laparoscopically especially in pedunculated cysts. A device of 2 coaxial suckers is presented to procure laparoscopic management of hydatid cysts enough safety against "spillage of contents" as in open surgery.

Laparoscopic management of superior mesenteric artery syndrome.

Superior mesenteric artery syndrome (SMAS) is a rare clinical condition that should be considered in patients with long-standing abdominal complaints where endoscopic and conventional roentgenographical findings are often negative. It has been claimed that SMAS is caused by intermittent obstruction of the horizontal portion of the duodenum between the superior mesenteric artery and the spine and the aorta. The main target of this presentation is to present our experience in the laparoscopic management of 4 cases of documented SMAS after failure of medical treatment. The laparoscopic severing of the ligament of Treitz is a feasible and safe technique. It could bring about total relief of symptoms in three out of the four patients. The operative time rapidly decreased with the acquaintance of the field. The visualization (exposure) is quite satisfactory. the technique offers added precision and accuracy to the dissection manoeuvres. Recovery was uneventful and rapid with minimal needs for postoperative analgesia. We recommend the use of mini-endoshear (pediatric). Phases of dissection from the mesocolon and retro-pancreatically are presented. We stress the finding of the drainage of the inferior mesenteric vein into the superior mesenteric vein instead of the splenic vein. This could put the inferior mesenteric vein (looking as a fibrous band) in jeopardy. Also it reduces the area of access to the retropancreatic dissection. We raise the possibility of an etiological role of this anatomical variation to the duodenal compression and call upon the study of such a possibility. The importance to attain the proper retropancreatic space has been shown by the possibility of dissecting between the uncinate process and the rest of the pancreas. The psychological impact of a minimal invasive approach together with symptoms relief was quite rewarding.