Total extraperitoneal access for parietal peritonectomy for peritoneal surface malignancy: The 'cocoon' technique.

OBJECTIVE: Complete surgical cytoreduction is the most important prognostic factor of survival in patients with peritoneal metastases from various cancers, including ovarian cancer. In order to achieve the optimum result, surgeons use extensive procedures that involve peritonectomies and multivisceral resections. Cytoreductive surgery (CRS) aims to eliminate all macroscopic disease by achieving complete cytoreduction. This article describes a surgical approach designed to achieve total extraperitoneal access for parietal peritonectomy. STUDY DESIGN: Visceral resections and parietal peritonectomy procedures must be conducted for complete removal of all visible malignancy. This article presents a technique that combines existing surgical approaches (anterolateral parietal peritonectomy, complete pelvic peritonectomy with sleeve resection of the sigmoid colon, and right and left upper quadrant peritonectomies) to achieve access to the upper abdomen, the lateral abdomen and the pelvis while keeping the peritoneum intact. RESULTS AND CONCLUSION: This approach facilitates the peritonectomies necessary for complete cytoreduction, and improves access to difficult sites such as the pelvis and the subdiaphragmatic areas in a standardized manner that can be reproduced safely by an experienced surgical team.

Unusual 31P Hyperfine Strain Effects in a Conformationally Flexible Cu(II) Complex Revealed by Two-Dimensional Pulse EPR Spectroscopy.

Strain effects on g and metal hyperfine coupling tensors, A, are often manifested in Electron Paramagnetic Resonance (EPR) spectra of transition metal complexes, as a result of their intrinsic and/or solvent-mediated structural variations. Although distributions of these tensors are quite common and well understood in continuous-wave (cw) EPR spectroscopy, reported strain effects on ligand hyperfine coupling constants are rather scarce. Here we explore the case of a conformationally flexible Cu(II) complex, [Cu{Ph2P(O)NP(O)Ph2-κ2O,O'}2], bearing P atoms in its second coordination sphere and exhibiting two structurally distinct CuO4 coordination spheres, namely a square planar and a tetrahedrally distorted one, as revealed by X-ray crystallography. The Hyperfine Sublevel Correlation (HYSCORE) spectra of this complex exhibit 31P correlation ridges that have unusual inverse or so-called "boomerang" shapes and features that cannot be reproduced by standard simulation procedures assuming only one set of magnetic parameters. Our work shows that a distribution of isotropic hyperfine coupling constants (hfc) spanning a range between negative and positive values is necessary in order to describe in detail the unusual shapes of HYSCORE spectra. By employing DFT calculations we show that these hfc correspond to molecules showing variable distortions from square planar to tetrahedral geometry, and we demonstrate that line shape analysis of such HYSCORE spectra provides new insight into the conformation-dependent spectroscopic response of the spin system under investigation.

Ten-year Audit of Safe Bail-Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy.

BACKGROUND: To prevent vasculobiliary injuries according to the Tokyo Guidelines, Critical View of Safety (CVS) is the recommended method for the identification of the cystic duct and cystic artery. Our aim was to audit laparoscopic cholecystectomies, in order to determine the rate of CVS feasibility and to explore safe bail-out alternatives, when CVS cannot be obtained. METHODS: Patients who underwent either elective or emergent laparoscopic cholecystectomy, between January 2009 and December 2018, in whom the CVS was attempted, were retrospectively identified from the institutional electronic database. Dissection technique was documented in the operative notes. Bile duct injuries (BDI) were classified by the Strasberg classification, and their management and outcome were reported in the patient files. RESULTS: In total, 1226 cases were included in the final analysis. CVS was feasible in 1128 cases (92.0%), whereas 65 patients (5.3%) were managed laparoscopically by a bail-out technique. Of those, 52 (4.3%) underwent a subtotal cholecystectomy, 12 (0.9%) a fundus-first cholecystectomy, and in one patient (0.1%) the operation was concluded by a tube cholecystostomy. Overall conversion rate was 2.7% (33/1226 cases). Male gender, older age, junior surgeons, and acute cholecystitis were significantly associated with higher conversion rates. Post-operatively, 10 patients (0.82%) developed a type A bile leakage. No major BDI (types B-E) were observed, either with CVS or the bail-out techniques. CONCLUSIONS: Our study showed that CVS and the bail-out alternatives complement each other in preventing major BDI and should belong to the armamentarium of every modern surgeon.

Incomplete bilateral duplication of the ureters identified during cytoreductive surgery for ovarian cancer: A case report.

INTRODUCTION: Incomplete bilateral ureteral duplication is a very rare condition. Ureteral duplication is often asymptomatic or may be associated with several urinary tract complications. CASE REPORT: We report a case of a 72- year- old Caucasian female who was referred to our clinic after she was diagnosed with FIGO IIIc ovarian cancer with peritoneal metastases. The patient underwent Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy. During the standard bilateral recognition of the ureters, intraoperatively, incomplete duplication of both of the ureters was identified. Bilaterally, the ureters were derived from a single renal parenchyma and duplication of the pyelocaliceal system in each kidney. DISCUSSION: The incomplete bilateral duplication of the ureters is a rare congenital renal abnormality. In a series of 51.880 autopsies ureteral duplication was observed in 0.66% of the cases, while in another autopsy series the ureteral duplication rate was 0.68%. CONCLUSION: Anatomical varieties of the ureter are of utmost importance for the surgeons, because they increase the possibility of iatrogenic ureteral injury. Ureteral injuries are severe complications of pelvic operations and may increase morbidity and even cause mortality.

Surgical Tips in Frozen Abdomen Management: Application of Coliseum Technique.

Wound dehiscence is a serious postoperative complication, with an incidence of 0.5-3% after primary closure of a laparotomy incision, and represents an acute mechanical failure of wound healing. Relatively recently the concept of "intentional open abdomen" was described and both clinical entities share common pathophysiological and clinical pathways ("postoperative open abdominal wall"). Although early reconstruction is the target, a significant proportion of patients will develop adhesions between abdominal viscera and the anterolateral abdominal wall, a condition widely recognized as "frozen abdomen," where delayed wound closure appears as the only realistic alternative. We report our experience with a patient who presented with frozen abdomen after wound dehiscence due to surgical site infection and application of the "Coliseum technique" for its definitive surgical management. This novel technique represents an innovative alternative to abdominal exploration, for cases of "malignant" frozen abdomen due to peritoneal carcinomatosis. Lifting the edges of the surgical wound upwards and suspending them under traction by threads from a retractor positioned above the abdomen facilitates approach to the peritoneal cavity, optimizes exposure of intra-abdominal organs, and prevents operative injury to the innervation and blood supply of abdominal wall musculature, a crucial step for subsequent hernia repair.

Simultaneous Gastric and Duodenal Erosions due to Adjustable Gastric Banding for Morbid Obesity.

Erosion is an uncommon but feared late complication of adjustable gastric banding for morbid obesity. A high index of clinical suspicion is required, since symptoms are usually vague and nonspecific. Diagnosis is confirmed on upper gastrointestinal endoscopy and band removal is the mainstay of treatment, with band revision or conversion to other bariatric modalities at a later stage. Duodenal erosion is a much rarer complication, caused by the connection tubing of the band. We present our experience with a case of simultaneous gastric and duodenal erosions, managed by laparoscopic explantation of the band, primary suture repair of the duodenum, and omentopexy.

Transient femoral nerve palsy complicating "blind" transversus abdominis plane block.

We present two cases of patients who reported quadriceps femoris weakness and hypoesthesia over the anterior thigh after an inguinal hernia repair under transversus abdominis plane (TAP) block. Transient femoral nerve palsy is the result of local anesthetic incorrectly injected between transversus abdominis muscle and transversalis fascia and pooling around the femoral nerve. Although it is a minor and self-limiting complication, it requires overnight hospital stay and observation of the patients. Performing the block under ultrasound guidance and injecting the least volume of local anesthetic required are ways of minimizing its incidence.

Mesothelial cyst of the round ligament misdiagnosed as irreducible inguinal hernia.

We report the case of a 36-year-old woman who presented with signs and symptoms of an irreducible inguinal hernia. Surgical exploration revealed a mesothelial cyst of the round ligament of the uterus. Mesothelial cysts of the round ligament are rare lesions, frequently masquerading as inguinal hernias, and should be included in the differential diagnosis of any inguinal mass. Clinical findings are those of a groin mass, discomfort, and bulging. Ultrasound and CT scans often demonstrate an aperistaltic cystic mass. Definitive diagnosis is usually made intraoperatively and confirmed histopathologically.

Extra-mammary Paget's disease of the perianal region: a review of the literature emphasizing the operative management technique.

The perianal skin is a common area for extra-mammary Paget's disease development. The unique clinical, histopathological, and immunohistochemical features which this medical phenomenon demonstrates, along with its rarity and frequent association with synchronous or metachronous carcinomas, present us with a treatment challenge. In order to organize the surgical treatment, it is important to determine whether the disease is localized exclusively to the perianal skin or associated with metastasis or anorectal carcinomas. Despite several controversies concerning its optimal therapeutic management, wide local excision of the skin and subcutaneous tissue in the perianal region is generally recommended for the treatment of the non-invasive form of the disease. Such an aggressive operative management usually results in a large perianal tissue defect, which can not be primarily suppressed without resultant tension and possible complications, requiring a special technique for its coverage. Various techniques have been described in the literature for the treatment of these defects, often associated with unfavourable long term results, i.e. split-thickness skin grafts and vacuum-assisted closure devices. More recently several authors have reported favourable results using various transposition or rotation local skin flaps, myocutaneous flaps of the gluteal and thigh muscles, and V-Y island flaps to cover these areas of tissue loss. In this article we present a short review of the literature concerning perianal Paget's disease with special attention to its management and a demonstration of the operative technique we prefer on patients with perianal non-invasive Paget's disease, i.e. wide local excision with a 2 cm margin in the anal mucosa and use of U and V-Y shaped perianal fatty-cutaneous island flaps for reconstruction by covering the bilateral anal skin defects.