Large abdominoscrotal hydrocele: Uncommon surgical entity.

INTRODUCTION: An abdominoscrotal hydrocele (ASH) consists of a large inguinoscrotal hydrocele which communicates in an hour glass fashion with a large "intraabdominal component". Mostly affects single testis but very rarely can present bilaterally. PRESENTATION OF CASE: We are presenting here a young 25 year old patient with large right sided scrotal swelling encroaching over lower abdomen. Clinically it was abdominoscrotal hydrocele which was confirmed with CT abdomen and later on subjected for surgery. DISCUSSION: Abdominoscrotal hydrocele is rarest type of hydrocele; first described by Dupuytren. The etiology of ASH is unknown; however, different theories have been described in literature to explain the pathogenesis. Diagnosis of ASH is done by clinical examination and is confirmed by radiological examination. Though ultrasonography is the first choice, in few selected cases contrast enhanced computerized tomography or magnetic resonant imaging may be helpful for more anatomical delineation. It may present with various complications secondary to pressure exerted by the components of the ASH. Surgical excision of the sac is the only definitive treatment option. There is no role of conservative treatment. Sometimes, decompression of the cyst needed to ease the dissection of the sac. CONCLUSION: Abdominoscrotal hydrocele differential should be considered while dealing with large lower abdominal swelling along with scrotal swelling.

Coexistence of pheochromocytoma/praganglioma and renal artery stenosis.

Renal artery stenosis (RAS) often coexists with pheochromocytoma (Pheo)/paraganglioma (PGL) and often alters the management of patients with Pheo/PGL. We have studied the prevalence of RAS in our Pheo/PGL patients. The study included 70 consecutive, histopathologically proven Pheo/PGL patients from a tertiary health care center. In 60 patients, tumors were limited to adrenal glands (54 unilateral and 6 bilateral) while other 10 patients had extra-adrenal abdominal tumors. Five patients had RAS with an overall prevalence of 14%. Only two out of 60 patients with Pheo had RAS with a low prevalence of 3.3% while three out of 10 patients with extra-adrenal abdominal PGL had RAS with a prevalence of 30%. To conclude, RAS commonly coexists with Pheo/PGL, more often with extra-adrenal PGL.

Laparoscopic adrenalectomy for large tumours: Single team experience.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat benign functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. This study aims to present our single unit experience of LA performed for large adrenal masses. MATERIALS AND METHODS: Forty-six laparoscopic adrenalectomies performed for large adrenal lesions more than 5 cm during the period 2001 to 2010 were reviewed. RESULTS: A total of 46 adrenalectomies were done in 42 patients. The mean tumour size was 7.03 cm (5-15 cm). Fourteen patients had tumour size more than 8 cm. The lesions were localised on the right side in 17 patients and on the left side in 21 patients with bilateral tumours in 4 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (range 20-400 ml) with the mean operating time being 144 min (range 45 to 270 min). Five patients required conversion to open procedure. Three of the 46 patients (6.52%) on final histology had malignant tumours. CONCLUSION: LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

Laparoscopic excision of a giant mesothelial omental cyst.

A 42-year-old patient presented with right-sided abdominal discomfort. Investigations revealed a 19 × 21 centimetres large cystic lesion occupying nearly the entire right side of the abdomen. It was situated between ascending colon and right kidney and extended from the liver to the pelvic inlet supero-inferiorly. Laparoscopic excision was planned. The cyst was aspirated completely and dissected from the surrounding structures. It was eventually found to be arising from the right free edge of the greater omentum. Due to its size and weight it was lodged behind the ascending colon. Post-operative course was uneventful. Histology revealed a mesothelial omental cyst. Omental cysts are rare abdominal tumours. Complete excision is the treatment advised to prevent recurrence. Laparoscopic excision can be safely performed taking care to ascertain diagnosis and not to damage any structures intra-operatively.

Laparoscopic adrenalectomy: Gaining experience by graded approach.

INTRODUCTION: Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success. MATERIALS AND METHODS: The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used. RESULTS: The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months). CONCLUSION: LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

Gastric cancer presenting with acute disseminated intravascular coagulation.

Patients presenting with acute disseminated intravascular coagulation (DIC) as the first symptom of malignancy are rare. A 68-year-old man presented with DIC. On evaluation, he was found to have adenocarcinoma of the stomach. Resection of the growth controlled the DIC for a few days, after which the patient developed altered coagulation parameters and sepsis, and succumbed.