Triple communicating complicated hepatic hydatid cyst: an unusual presentation and laparoendoscopic management.

Echinococcal disease in humans had been widely reported in the literature for its unusual presentation and location. We discuss a rare case of suppurated left hepatic hydatid cyst with contaminant transdiaphragmatic rupture communicating into the right pleural cavity along with fistulisation of cyst into the left hepatic duct and stomach which is very rare according to our knowledge. A 65-year-old man presented to us with features of cholangitis and sepsis. Initial radiological investigations revealed multiloculated cystic mass in the left lobe of cirrhotic liver communicating with the left hepatic duct and extending to the right pleural cavity with dilated common bile duct. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis yielding hydatid membranes with presence of transgastric fistula in the left hepatic duct and provided postoperatively continuous internal drainage. Old age, complicated cyst, compromised respiratory status, sepsis and cirrhotic liver precluded us to plan for conservative surgical approach (laparoscopic drainage of mediastinal contents) with successful outcome.

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients.

OBJECTIVES: Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases. METHODS: Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented. RESULTS: Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients. CONCLUSIONS: Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

NOTES: Transvaginal endoscopic cholecystectomy in humans-preliminary report of a case series.

OBJECTIVES: Natural orifice translumenal endoscopic surgery (NOTES) represents an emerging technology, including under its umbrella a variety of approaches and combinations. The transvaginal approach to endoscopic cholecystectomy is one such technique, which we present here as a small series. METHODS: From May to November 2007, a total of eight patients were scheduled to undergo transvaginal endoscopic cholecystectomy at our institute. Two patients were excluded as they were converted to laparoscopy due to technical difficulties. RESULTS: Average age of the patients was 34.5 years, and mean body mass index was 27 kg/m(2). The mean operating time was 148.5 min. Patients were discharged in an average of four postoperative days. The major complication rate was 16% (1/6). The patient with a major complication had a subhepatic collection that was managed with ultrasonogram-guided aspiration followed by ERCP and stenting. CONCLUSIONS: Since the first description of NOTES, there has been no standardized technique. In our technique, we used a single 3-mm trocar for visualizing the entry and exit of the endoscope, maintaining and measuring pneumoperitoneum, and retracting the gall bladder fundus. The instruments that were used were the conventional endoscopic ones. The transvaginal approach seems to be a viable alternative to the transgastric approach for cholecystectomy, as the transgastric approach has certain inherent problems like leakage from the gastrotomy site and poor ergonomy. The downside to the transvaginal approach is that it is possible only in women.

Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES--world's first report.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is the newest technique emerging in the field of surgery. There are several techniques described in the literature; however there is no standardization yet. We describe the transvaginal approach for endoscopic appendectomy in humans, probably the world's first report. MATERIALS AND METHODS: Pneumoperitoneum was achieved via a Veress needle in the umbilicus. Routine 12-mm endoscope and routine instruments were used. Peritoneal access was gained via a transvaginal approach through the posterior fornix. RESULTS: Out of a total of six patients, a totally endoscopic transvaginal appendectomy was successfully performed for one patient. The other five patients were either converted to conventional laparoscopy or aided by a laparoscope. The average age of the patients was 29.5 years. The mean operating time was 103.5 min. Hospital stay was 1-2 days. The follow-ups were scheduled at 7 days, 30 days, 90 days, and 6 months. The vaginal wound was examined by the gynecologist and found to have completely healed during the first and second follow-up. DISCUSSION: So far in humans, transgastric appendectomy and cholecystectomy, and transvaginal cholecystectomy have been reported. A transvaginal endoscopic appendectomy in humans has not been reported yet. The transvaginal approach provided a normal image of the target organ, unlike the inverted image of a transgastric approach caused by the inability to manipulate the scope outside the mouth. The technical ease of the procedure and early outcome seem satisfactory, although comparative studies are needed to confirm this.

Laparoscopic management of acid peptic disease.

BACKGROUND: Despite successful medical treatment to reduce acid hypersecretion and eradicate Helicobacter pylori, surgery still plays an important role in the management of complicated peptic ulcer disease. Almost all types of conventional operations available for ulcer disease have been successfully performed by the laparoscopic approach and this has become the preferred approach in tertiary centers for operative management of acid peptic disease. METHOD: Between 1995 and 2004, laparoscopic management was offered to refractory or obstructive acid peptic disease patients. For intractable disease, we performed either posterior truncal vagotomy with anterior fundal seromyotomy or posterior truncal vagotomy with anterior proximal gastric vagotomy. For peptic ulcer disease complicated with gastric outlet obstruction, we carried out bilateral truncal vagotomy with gastrojejunostomy. RESULTS: Two hundred sixty three patients were operated of whom 236 (89.7%) were men and the average age of the patients was 48.4 years. Thirty-two (12.2%) patients underwent posterior truncal vagotomy with anterior seromyotomy, 89 (33.8%) underwent posterior truncal vagotomy with anterior proximal gastric vagotomy, 120 (45.6%) underwent bilateral truncal vagotomy with stapled gastrojejunostomy whereas 22 (8.4%) underwent bilateral truncal vagotomy with hand-sewn gastrojejunostomy. The average operating times were 142, 110, 98, and 72 minutes, respectively. The average postoperative stay was 5.4 days. CONCLUSIONS: Laparoscopic posterior truncal vagotomy with anterior proximal gastric vagotomy for refractory disease and laparoscopic bilateral truncal vagotomy with stapled gastrojejunotstomy for obstructive disease have become the standard at our institution. Regardless of the preference of individual surgeon, our results have shown that laparoscopic surgery may become the gold standard for surgical management of peptic ulcer disease.

Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants.

BACKGROUND: Open cholecystectomy is associated with considerable morbidity and mortality in cirrhotic patients. Laparoscopic cholecystectomy may offer a better option because of the magnification available and the availability of newer instruments like the ultrasonic shears. We present our experience of 265 laparoscopic cholecystectomies and attempt to identify the difficulties encountered in this group of patients. STUDY DESIGN: Between 1991 and 2005, 265 cirrhotic patients of Child-Pugh Classification A and B, with symptomatic gallstones, were subjected to laparoscopic cholecystectomy. We describe here our tailored approach and our techniques of subtotal cholecystectomy. RESULTS: Features of acute cholecystitis were present in 35.1% of the patients, and 64.9% presented with chronic cholecystitis. In 81.5% of the patients, the diagnosis of cirrhosis was established preoperatively. In 8.3% of the patients, a fundus first method was adopted when the hilum could not be approached despite additional ports. Modified subtotal cholecystectomy was performed in a total of 206 patients. Mean operative time in the subtotal cholecystectomy group was 72 minutes; in the standard group, it was 41 minutes. There was no mortality. In 15% of patients, postoperative deterioration in liver function occurred. Worsening of ascites, port site infection, port site bleeding, intraoperative hemorrhage, bilious drainage, and stone formation in the remnant were the other complications encountered. CONCLUSIONS: Laparoscopic cholecystectomy is a safe and effective treatment for calculous cholecystitis in cirrhotic patients. Appropriate modification of subtotal cholecystectomy should be practiced, depending on the risk factors present, to avoid complications.

Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients.

BACKGROUND: To evaluate outcomes after minimally invasive or thoracolaparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. Esophagectomies are being performed increasingly by a minimally invasive route with decreased morbidity and shorter hospital stay compared with conventional esophagectomy. Most series report thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in the left lateral position with respiratory complications up to 8% and prolonged operative time, probably because of inadequate stance of the surgeon during the thoracoscopic part. This study shows the potential of the thoracoscopic part of the procedure in prone position to ease these difficulties. STUDY DESIGN: From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proved squamous cell carcinoma of the middle third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics, translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients. RESULTS: There were 102 men and 28 women. Median age was 67.5 years (range 38 to 78 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 32 days) and median hospital stay was 8 days (range 4 to 68 days). Perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean followup of 20 months (range 2 to 70 months), stage-specific survival was similar to open and other minimally invasive series. CONCLUSIONS: TLE with thoracoscopic part in prone position is technically feasible, with a low incidence of respiratory complications and less operative time required. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (1.54%), hospital stay of 8 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.