Laparoscopic treatment of Spiegel hernia by total extraperitoneal (TEP) approach.

BACKGROUND: Spiegelian hernia is a rare type of ventral abdominal hernia. Surgical treatment is recommended due to the high risk of complications. Laparoscopic treatment is preferred to open repair, by means of intraperitoneal or extraperitoneal mesh placement, either by transperitoneal(TAPP) or by total extraperitoneal (TEP) approach. Total extraperitoneal approach is rarely reported in the literature. AIM: To evaluate the results of laparoscopic repair of Spiegelhernia by total extraperitoneal approach. MATERIAL AND METHOD: We prospectively studied the patients operated on for Spiegel hernia between October 2009 and March 2013 by laparoscopic TEP approach at Ponderas Hospital. Data regarding symptoms, sex, preoperative work-up,surgical technique, hospital stay and outcome of the procedure were analysed. Follow-up of the patients was achieved at 1week, 1 month, 6 months and yearly postoperatively and patients were evaluated for recurrence, chronic pain, mesh infection, time to reinsertion to normal activities and overall patient satisfaction score. RESULTS: We have treated 4 patients with Spiegel hernia by laparoscopic TEP repair, with mean age 55.25 years (range 50-64), sex ratio 1 (2 2); all patients were symptomatic, all cases had left sided hernias, the surgical intervention was elective in all cases. Mean hospital stay was 1.5 days (range1- 2 days). There was only one postoperative complication ina patient with asymptomatic seroma, with remission in 1 month. There were no recurrences, no mesh infection, no chronic pain or other morbidity at a mean follow-up of 25 months (range 12-53 months). The overall satisfaction score was maximal (5) in all cases. CONCLUSIONS: Spiegelian hernias are rare but surgery is mandatory because of the risk of complications like incarceration and strangulation. In the presented experience, laparoscopic total extraperitoneal approach proved to be an efficient technique,reproducible, with excellent results for Spiegel hernia treated electively.

Laparoscopic surgery complications: postoperative peritonitis.

INTRODUCTION: Complications within laparoscopic surgery, similar to classic surgery are inevitable and require immediate actions both to diminish intraoperative risks and to choose the appropriate therapeutic attitude. Peritonitis and hemorrhagic incidents are both part of the complications aspect of laparoscopic surgery. Fortunately, the incidence is limited, thus excluding the rejection of celioscopic methods. Patient's risks and benefits are to be analyzed carefully prior recommending laparoscopic surgery. MATERIALS AND METHODS: This study presents a statistical analysis of peritonitis consecutive to laparoscopic surgery, experience of "Sf. Ioan" Emergency Hospital, Bucharest, and Department of Surgery (2000-2010). RESULTS: There were 180 (0,96%) complicated situations requiring reinterventions, from a total of 18676 laparoscopic procedures. 106 cases (0,56%) represented different grades of postoperative peritonitis. Most frequently, there were consecutive laparoscopic appendicectomia and colecistectomia. During the last decade, few severe cases of peritonitis followed laparoscopic bariatric surgical procedures. CONCLUSIONS: This study reflects the possibility of unfavorable evolution of postoperative peritonitis comparing with hemorrhagic incidents within laparoscopic surgery.

[The problem of iatrogenic common bile duct injury, or the picture of an iceberg peak]. / Problematica leziunilor iatrogene de cale biliara principala, sau o imagine a unui vârf de aisberg.

UNLABELLED: The goal of this study was to increase the awareness of the problem of iatrogenic common bile duct injury. METHODS: A retrospective review of the biliary primary or redo reconstructions performed at our clinic, for iatrogenic injuries, was done. A total of 34 cases were followed for 2 to 16 (mean 8.5 +/- 4.5) years in order to asses their long-term outcomes. RESULTS: There were 8 Strasberg D lesions and 26 Strasberg E lesions. The mortality rate was 6% (2 patients). The mid and long term outcomes were good in 82% cases (28 patients). Over all there were 108 surgical, radiological or endoscopic interventions (mean 3.2 +/- 1.8). Only 2 patients didn't have a complicate course after the initial surgery. We have counted 87 (mean 2.5 +/- 2.9) complications, 107 (mean 3.1 +/- 2.2) hospital admissions, and 1182 (mean 37 +/- 25) hospitalization days. General and local sepses were the main risk factors for the failure of the biliary reconstruction. CONCLUSIONS: As a rule, iatrogenic common bile duct injuries have a complicated postoperative course, with many hospital admissions and surgical, endoscopic or radiological interventions. Before biliary reconstruction, every attempt must be done to prevent or control general and local sepsis. Biliary injuries are more easy to prevent than to treat.

[Laparoscopic training--the guarantee of a future in pediatric surgery]. / Trainingul laparoscopic--certitudinea unui viitor în chirurgia pediatrica.

Laparoscopy is considered today the highlight of modern surgery, the forerunner of the fascinating world of video and robotic surgery, both of them derived from the sophisticated areas of aeronautic industry. Remarkably, Romanian specialists keep up with the pace of worldwide technological developments, assimilating one by one each and every video endoscopic procedure. In the early 90s, the Romanian laparos-copic school was founded with the contribution of many important personalities; their activities and achievements have been an inspiration for the following generation of laparoscopic surgeons. In this last decade, the newest branch of laparoscopic surgery in our country, pediatric laparoscopy, managed to evolve from its "shy" beginnings to become an important method of improving the quality of surgical procedures, to the benefit of our "small patients". The purpose of this article is to encourage and promote minimally invasive video endoscopic surgery training, emphasizing its crucial role in the education and professional development of the next generation of pediatric surgeons, and not only. The modem concept of laparoscopic training includes experimental scientific practices, as well as the newest technical acquisitions such as virtual reality video-electronic simulation.

[The pig model for the laparoscopic antireflux surgery training]. / Modelul suin pentru antrenament în chirurgia laparoscopica anti reflux.

The laparoscopic treatment of the Gastroesophageal Reflux Disease (GERD) includes antireflux surgery (AR) procedure which may be performed in an optimal functional manner. To achieve this target adequate training is mandatory for the surgical team. In the "Sf. John" Laparoscopic Training Center (Bucharest, Romania) we have studied the advantages and disadvantages of a pig model for training in laparoscopic antireflux surgery. 16 pigs (20-25 kg) were included in this study. The results of this study included: 1. a complete description of the laparoscopic Nissen fundoplication in pigs and 2. the evaluation of the pig model for laparoscopic AR surgery. The use of pigs with anesthesia as a training model for laparoscopic AR surgery present certain advantages for the trainees: clear and humans similar anatomy, real surgical conditions (OR, equipment, instruments, lived animals).

[Laparoscopic hysterectomy]. / Histerectomia laparoscopica.

Our paper presents the experience gained in nearly 12 years by the General Surgery Clinic of "Sfantul Ioan" Hospital, Bucharest in the field of laparoscopic hysterectomy. The period of time is quite long compared to the evolving of mini-invasive techniques and also unequal towards the experience of the surgeons who perform these procedure. The total number of hysterectomies was 1491 from which 251 by laparoscopic approach, the rest being made by the classic methods (most of them by laparotomy and some by vaginal approach). In the statistic we have included 15 myomectomies, 4 cases of radical hysterectomy with pelvic lymphadenectomy and 4 cases of complete hysterectomy after partial procedures made by laparotomy. The indications were represented mostly by uterine fibroma (82.07%), but also by uterine prolapse (13.14%), uterine bleeding, cervix severe dysplasia, uterine and cervix neoplasia (stage I) or associated to ovariectomy related to breast cancer. The paper analyses the results looking at the incidents and accidents (hemorrhagic, ureteral, urinary bladder or rectal lesions) and also postoperative complications (we had three reinterventions, two by laparoscopy and one by laparotomy). We also recorded one death not directly as a consequence of surgery, but as a diagnosis error. Regarding the surgical technique we initially chose the laparoscopic assisted vaginal hysterectomy. Afterwards by gaining experience we started treating the uterine pedicle and now we settled for the integral laparoscopic procedure. In our opinion laparoscopic hysterectomy represents all the advantages of mini-invasive approach. The technological development, but essentially the experience gained by surgeons are the key factors in accepting and promulgating the technique.

[Hynes-Andersen pyeloplasty by mini-laparoscopy transperitoneal approach]. / Pieloplastie Hynes-Andersen pe cale minilaparoscopica transperitoneala.

Laparoscopy had significantly gained in the field of urologic surgery, almost all the surgical procedures in the retroperitoneal space being made, from the simple ones (renal cystectomy, varicocelectomy) to the ones requiring higher expertise (nephrectomy, adrenalectomy) by retro-peritoneoscopy and also transperitoneal. At the Surgery Department of "Sf. Ioan" Hospital, Bucharest, we approached initially the retroperitoneal pathology by lomboscopy, but afterwards we choose the transperitoneal approach because of the generous workspace and the clearer anatomical landmarks, regardless of the procedures (renal cystectomy, varicocelectomy, adrenalectomy, nephrectomy, pyelo-lithotomy, ureterolithotomy). In association with the Urology Department of "Sf. Ioan" Hospital we practiced two Hynes Andersen pyeloplasty for pyelo-ureteral junction stenosis by transperitoneal approach, using mini-laparoscopy tools. In one of the cases we also perform a basinetal lithotomy.

[Laparoscopic surgery for small bowel obstruction]. / Abordul laparoscopic al ocluziei intestinului subtire.

At the beginning of the laparoscopic surgery, intestinal obstruction was considered an absolute contraindication for this approach, because of the high risk of injuring the bowel. Today, the increased experience allows to apply this method in certain selected cases of small intestine obstruction. We realised a retrospective study, over a period of 7 and a half years (January 1997 - June 2004), regarding the patients admitted and treated in our department for small intestine obstruction, both by open surgery (88 cases) and by laparoscopic surgery (11 cases). We compared the preoperative characteristics of the two subgroups, highlighting the importance of a careful selection of the cases for the success of the laparoscopic approach. We analysed the postoperative evolution of these patients (return of bowel function, postoperative wound evolution, hospital stay, socioeconomic reintegration), which allowed us to draw the conclusion that some of the patients with obstruction of the small intestine may benefit from the advantages of the mini-invasive surgery.

[Intraabdominal malignant pathology missed at laparoscopic cholecystectomy]. / Patologie maligna abdominala omisa la colecistectomia laparoscopica.

Due to its overwhelming benefits, laparoscopic cholecystectomy represents the "gold standard" for the treatment of symptomatic gallbladder stones. Allowing us to quickly solve an easy to diagnose pathology (by ultrasonography), in some cases it may lead us to mis-diagnose some major intraabdominal pathology, perhaps by a superficial interpretation of our clinical examination and para-clinic investigation data. Studying the archives of our clinic from January 1995 up to December 2003, we found 15 cases of intraabdominal neoplasia diagnosed in the year that followed laparoscopic cholecystectomy: 7 colorectal cancers, 4 pancreatic cancers, 2 gastric carcinomas, one uterine and one adrenocortical malignancies. Among these, 6 cases were in an advanced stage--because of local invasion or distant metastases--without the possibility of radical, curative surgery. Only 4 of the 15 cholecystectomies were performed for acute cholecystitis. The average age was 56.3 years, under the age when such malignancies have the maximum incidence.

[Laparoscopic appendectomy--considerations in about 1000 cases]. / Apendicectomia laparoscopica--consideratii pe baza a 1000 de cazuri.

Laparoscopic appendectomy (LA) is a well spread method today, but not as largely accepted as cholecystectomy, the cure of gastro-esophageal reflux and some other procedures (relatively small in number) for which the laparoscopic approach is the golden standard. Otherwise it is improbable that LA will gain such a status, at least in the near future. On the other hand it is obvious that LA offers important advantages for some special situations: the right iliac area syndrome, obesity, professional sportsmen, abnormal localization of the appendix, as well for the cases when localized and especially diffuse peritonitis is associated. Our paper analyses the experience of General Surgery Department at the "St.John" Emergency Hospital Bucharest on laparoscopic appendectomy. The retrospective study includes 996 cases that were treated laparoscopic between 1996-2004. Of these 745 cases were catarrhal, 166 cases were phlegmonous and 76 gangrenous appendicitis. In 93 cases localized or diffuse peritonitis was associated. There were recorded also 3 cases of each of the following: chronic appendicitis, appendicular mass and mucocele. The number of conversions was 28 (2.81%). There were also 10 reinterventions (1.004%), 7 because of intraperitoneal abscess and we also recorded one death.

[Cavitary viscera injuries during laparoscopy]. / Leziuni ale viscerelor cavitare în cursul interventiilor laparoscopice.

Intraoperative incidents of laparoscopic surgery resulting in cavitary viscera injuries are analyzed, based on a series of 6308 patients (6800 operations) operated during a period of 9 years. This retrospective study includes 11 cases: 6 intraoperative cavitary viscera perforations (esophagus, gastric fornix, ileum, sigmoid) have been recognized and solved in the same laparoscopic operation or after conversion. In 5 cases the diagnosis was established in the postoperative period as fistulas (urinary bladder) or diffuse peritonitis caused by various types of injuries (esophagus, small and large bowel) and required reoperations. We present a global view of these cases and also analyze the determinant causes of the complications, emphasize the importance of intraoperative identification of such injuries and specify the place of minimally invasive surgery in the treatment of such accidents with an optimum healing and low rate of postoperative morbidity and mortality.

[Laparoscopic mini gastric bypass for the treatment of morbid obesity. Initial experience]. / Derivatia minigastrica pe cale laparoscopica pentru tratamentul obezitatii morbide. Experienta initiala.

The mini-invasive treatment of morbid obesity represents a priority of our surgical team. The majority of the patients have been operated on restrictive bariatric procedures. The technique we are presenting is indicated for the extreme and super obese patients (BMI >50 kg/m2) for whom the restrictive procedures are less efficient. In these situations we have performed a mixed procedure, combining two principles restriction and malabsorption by creating a low capacity gastric tube connected to the jejunum through a linear stapled anastomosis. The name of these procedure is mini gastric bypass and our experience is consisting of 7 patients, with BMI between 52.7 and 71.69 kg/m2, with very important comorbidities. In this paper we are describing the specifics of the laparoscopic approach and the postoperative results at 3-18 months. We have recorded one conversion to the open surgery, two hemorrhagic postoperative complications and one marginal ulcer (3 month post-operatively); all complications were treated conservatively. All the patients lost weight, the EWL at 12 months was between 45.26% and 77.65%, while the co-morbidities had a significant good evolution. The procedure was efficient, well accepted and tolerated by the patients.

[Laparoscopic approach in large hiatal hernia--particular considerations]. / Abordul laparoscopic în herniile hiatale voluminoase--consideratii particulare.

UNLABELLED: Large hiatal hernia are associated with permanent or intermittent protrusion of more than 1/3 of the stomach into the chest, single or in associated with other organs, a hiatal defect greater than 5 cm and various complications related to the morphological and physiological modifications. While the laparoscopic approach in small hiatal hernia and gastro-esophageal reflux disease is a standard procedure in large hiatal hernia persists a number of questions and controversies. Between 1995 and 2002 a number of 23 patients with large hiatal hernia (9 men, 14 women), mean age 65.8 years (range 49 to 77) underwent laparoscopic surgery. The majority of the patients had complications of the disease (dysphagia, severe esophagitis, anemia, respiratory and cardiac failure). In 16 cases was a sliding hernia (one recurrent after open procedure), in 2 paraesophageal and in 5 a mixed hernia (two "upside-down" type). In 7 cases we perform, in the same operation, cholecystectomy for gallbladder stones and in one cases Heller myotomy for achalasia. In all cases the repairs was performed by using interrupted stitches to approximate the crurae, but in three of them (recurrent and upside down hernia) we consider necessary to repair with a polypropylene mesh (10 x 5 cm) with a "keyhole" for the esophagus. In these particular cases we do not perform a antireflux procedure, in others 20 cases a short floppy Nissen was done. During the operation one patient developed a left pneumothorax and required pleural drainage. Postoperatively one patient had dysphagia treated by pneumatic dilatation and another die 3 weeks after the surgery because severe respiratory and cardiac failure. CONCLUSIONS: Laparoscopic approach is a feasible and effective procedure with good postoperatively results, but required good skills in mininvasive technique.

Nature and prevalence of risk factors associated to type B and C acute viral hepatitis cases in Bucharest, 1998-2000.

The main objective of the study was to calculate and report the prevalence of probable risk factors involved in the transmission of pathogenic agents among type B and C acute viral hepatitis cases confirmed in Bucharest (1998-2000). The standardized values of the risks detected in the 45-180 days preceding the onset of illness suggest that in both types of acute viral hepatitis considered in our study transmission associated to the individuals' behaviour (19.0%-hepatitis B and 20.1%-hepatitis C) seems more frequent than "iatrogenic" transmission; in case of hepatitis B, sexual contacts with more than one partner coming first (15.7%), whilst in case of hepatitis C the use of i.v. drugs (heroine) was most frequently incriminated (12.4%). The study reviews the present knowledge of the risk factors involved in the transmission of the disease and approaches prevention strategies.

[Laparoscopic reoperations]. / Reinterventii laparoscopice.

The progress of laparoscopic techniques have made possible video-assisted miniinvasive surgery in patients with indication of reoperation. Knowing that there are many controversies against this type of surgery, the authors tried to formulate their own point of view in this matter by analyzing their experience in such particular cases. In this study there are included both laparoscopic re-operations (or re-laparoscopies), consecutive to video-assisted surgery, and the mini-invasive procedures performed for complications after open surgery. Of the total 3901 laparoscopic operations (in 3714 patients) we performed 34 laparoscopic re-operations for postoperative complications occurred in patients previously operated on in our clinic or in other departments (29 re-laparoscopies and 5 after open surgery) The objective of the study was to verify if the laparoscopic techniques are useful in diagnostic and treatment of the postoperative complications which need surgical re-exploration, and the conclusions have shown that laparoscopy may be appropriate in re-exploration of the surgical patients, if the rules of the operative management is respected and the well defined standards are fulfilled.

[Conversions and reinterventions in laparoscopic cholecystectomy]. / Conversii si reinterventii în colecistectomia laparoscopica.

From the introduction of the laparoscopy in our clinic, more and more of the cholecystectomies, reaching over 50% are done by this technique. Based upon the accumulation of an already important experience, the paper tries to analyze the situations in which, during or after laparoscopic cholecystectomy, intraoperative conversions (deliberate or of necessity) or reinterventions were necessary. We present a global view of the number of these cases and also (an in detail) analysis of the causes the imposed such decisions and of the solutions adopted. The percentages of 5.55 conversions and 1.49 reinterventions seem reasonable and acceptable in comparison with the initial results published by some experience surgeons in the field of laparoscopic surgery.

[A voluminous hepatic hydatid cyst of the right lobe in a patient with hypertrophic liver cirrhosis--comments on a case]. / Chist hidatic hepatic voluminos al lobului drept, la un pacient cu ciroza hepatica hipertrofica--discutii pe marginea unui caz.

There is presented the case of a patient with liver cirrhosis hepatomegalic form, echinococcosis and gallbladder stones. After the presentation of the clinical findings, there are discussed the problems of the surgical treatment. The remaining cavity was treated by pericysto-jejunostomy. The postoperative recovery was uneventful.