Comparison Of Operative Complications Of Direct Trocar Access Versus Veress Needle Insertion Technique For Initial Peritoneal Entry In Patients Undergoing Gynecological Laparoscopic Surgery.

BACKGROUND: Laparoscopy is considered to be a good diagnostic and surgical way to replace open surgeries in all surgical fields. As it is a least invasive method, with advantages for patients and all associated with medical care. There is a significant increase in the use of laparoscopic surgery in gynecology. This study was done to compare the frequency of operative complications of direct trocar access versus Veress needle insertion technique for initial peritoneal entry in patients undergoing gynecological laparoscopic surgery. METHODS: This Randomized Controlled Trial was conducted at the Department of Obstetrics & Gynecology, Lahore General Hospital, Lahore from 26-12-2019 to 25-6-2020. Four hundred consecutive patients were enrolled and divided randomly into two groups by blocked randomization. Direct trocar insertion (DTI) technique was used for initial peritoneal access in group A and Veress needle (VNI) was inserted first for peritoneal access in group B. RESULTS: The mean age of the patients in DTI group was 35.76±8.38 years whereas that in VNI group was 35.85±8.38 years. In DTI group there were 8(4%) patients with extra-peritoneal insufflation and in VNI group there were 19(9.5%) patients with extra-peritoneal insufflation. There were 8(4%) patients in DTI group with Omental injury and VNI group there were 13(6.5%) patients with Omental injury. In DTI group there were 7(3.5%) patients with port-site infection compared to 15(7.5%) in VNI group. CONCLUSIONS: According to findings the rate of complications observed with VNI, DTI can be a preferred procedure for gynecological surgeries.

Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience.

BACKGROUND AND AIMS: Selective nonoperative management of abdominal stab wound is well established, but its application in the setting of isolated omental evisceration remains controversial. The aim of the study is to establish the role of selective nonoperative management in the setting of isolated omental evisceration. MATERIALS AND METHODS: A retrospective study was conducted over an 8-year period from January 2010 to December 2017 at a major trauma center in South Africa to determine the outcome of selective nonoperative management. RESULTS: A total of 405 consecutive cases were reviewed (91% male, mean age: 27 years), of which 224 (55%) cases required immediate laparotomy. The remaining 181 cases were observed clinically, of which 20 (11%) cases eventually required a delayed laparotomy. The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), 3-6 h in 6% (14/244), 6-12 h 2% (4/244), and 12-18 h in 1% (2/244). There was no significant difference between the immediate laparotomy and the delayed laparotomy group in terms of length of stay, morbidity, or mortality. Ninety-eight percent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. CONCLUSION: Selective nonoperative management for abdominal stab wound in the setting of isolated omental evisceration is safe and does not result in increased morbidity or mortality. Clinical assessment remains valid and accurate in determining the need for laparotomy but must be performed by experienced surgeons in a controlled environment.

Radiographic and CT features of colonic entrapment due to an omental rent in a dog.

A 2-year-old female spayed Great Dane presented for inappetence and lethargy. Abdominal radiographs revealed a severely gas-distended segment of colon. Computed tomography was performed and characterized a 180° anticlockwise colonic torsion with entrapment in a mesenteric/omental rent without vascular compromise. Exploratory laparotomy confirmed entrapment, but not colonic torsion. Computed tomography provided important information to assist clinical management decisions for this dog with colonic entrapment.

Comparison of laparoscopic and open pyloromyotomy: Concerns for omental herniation at port sites after the laparoscopic approach.

Pyloromyotomy is a common surgical procedure in infants with hypertrophic pyloric stenosis and can be performed with a small laparotomy or laparoscopically. No specific complications have been documented about one of the approaches. We aim to study (severity of) complications of pyloromyotomy and to compare complications of both approaches. Children undergoing pyloromyotomy between 2007 and 2017 were analyzed retrospectively. Complication severity was classified using the Clavien-Dindo classification. We included 474 infants (236 open; 238 laparoscopic). 401 were male (85%) and median (IQR) age was 33 (19) days. There were 83 surgical complications in 71 patients (15.0%). In the open group 45 infants (19.1%) experienced a complication vs. 26 infants in the laparoscopic group (10.5%)(p = 0.013). Severity and quantity of postoperative complications were comparable between both groups. Serosal tears of the stomach (N = 19) and fascial dehiscence (N = 8) occurred only after open pyloromyotomy. Herniation of omentum through a port site occurred only after laparoscopy (N = 6) and required re-intervention in all cases. In conclusion, the surgical complication rate of pyloromyotomy was 15.0%. Serosal tear of the stomach and fascial dehiscence are only present after open pyloromyotomy and omental herniation after laparoscopy respectively. The latter complication is underestimated and requires attention.

Mesenchymal Stem Cell-injected Omental Patch More Effective Promoting Wound Healing in Bowel Perforation Animal Model.

INTRODUCTION: Bowel perforation (BP) occurs as the complication of many gastrointestinal problems. Omental patch (OP) is one of the methods to place omentum flaps in the perforated area. Mesenchymal stem cells (MSCs) may increase regeneration process in all tissues. AIM: to demonstrate the role of MSC in accelerating of wound healing process by analyzing fibroblast and collagen appearance in perforated bowel conditions. METHODS: Using a BP rabbit model, 18 rabbit were randomly assigned into three groups: combination of umbilical cord (UC)-MSCs injection and OP (T1), OP only (T2) and vehicle control (Veh). Hematoxylin-eosin staining and Masson's trichrome staining were performed to analyze the level of fibroblast and collagen. Wound length were measured using standardized caliper. RESULTS: The study showed a significant (P<0.05) increase of fibroblast and collagen amount on T1 and T2, in which T1 was higher than T2. This result was also followed by the decrease of wound length. CONCLUSION: The combination of MSCs and OP-sutured in perforated bowel are better to accelerate wound healing than OP only in BP cases.

The spectrum of injuries resulting from abdominal stab wounds with isolated omental evisceration: A South African experience.

INTRODUCTION: The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature in the specific setting of isolated omental evisceration is limited. MATERIALS AND METHODS: We reviewed our experience of 244 consecutive patients with established indications for laparotomy over an eight year period at a major trauma centre in South Africa. RESULTS: Of the 244 patients (93% male, mean age: 27 years), 224 (92) underwent immediate laparotomy (IL). Twenty were initially observed and eventually required a laparotomy (delayed laparotomy, DL). The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), <6 h in 6% (14/244), <12 h 2% (4/244) and <18 h in 1% (2/244). Ninety-eight per cent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. The mostly commonly injured organ encountered on laparotomy were small bowel, stomach and colon. CONCLUSIONS: The most commonly injures encountered are intestinal and gastric. Clinicians must remain vigilant as injuries may be subtle.

Reconstrução de extenso defeito da parede torácica anterior pós-mediastinite com retalho de omento: relato de caso / Reconstruction of an extensive anterior chest wall defect after mediastinitis with an omentum flap: a case report

Apresentamos o caso de um paciente de 70 anos de idade que evoluiu com extenso defeito cutâneo em parede torácica anterior após ter sido submetido a revascularização do miocárdio e mediastinite pós-operatória. Pela impossibilidade de utilização de retalhos cutâneos e musculares da região, fizemos a reconstrução com a rotação de retalho de omento baseado na artéria gastroepiploica esquerda e enxerto de pele em malha.

We report the case of a 70-year-old patient who developed an extensive skin defect in the anterior chest wall after undergoing myocardial revascularization and postoperative mediastinitis. Owing to the impossibility of using cutaneous and muscular flaps on the region, we performed the reconstruction with an omentum flap based on the left gastroepiploic artery and meshed skin graft.

Rentabilidad diagnóstica de la biopsia con aguja gruesa guiada por técnicas de imagen del mesenterio y del peritoneo / Diagnostic performance of imaging-guided core needle biopsy of the mesentery and peritoneum

Objetivo. Evaluar la rentabilidad de la biopsia percutánea con aguja gruesa guiada por técnicas de imagen de nódulos e infiltración difusa del omento o del peritoneo. Material y métodos. Se evalúan retrospectivamente 57 pacientes a los que se realizó una biopsia con aguja gruesa del peritoneo o del omento entre marzo de 2014 y enero de 2017. La tomografía computarizada (TC) al diagnóstico se empleó para planificar la biopsia. Los resultados se clasificaron en diagnósticos (benignos/malignos) o no concluyentes (muestra insuficiente). Se calcularon la sensibilidad, la especificidad y el valor predictivo positivo y negativo. Se analizó si la muestra fue diagnóstica según la técnica de imagen empleada (TC o ecografía) y el tipo de afectación del omento-peritoneo biopsiada (masa, nódulo o infiltración difusa). Resultados. El 100% de las biopsias percutáneas fueron diagnósticas. La sensibilidad de la técnica fue del 98,18% y la especificidad fue del 100%. El valor predictivo positivo fue del 100% y el negativo fue del 50%. Tanto las muestras obtenidas con guía por TC (10) como las guiadas por ecografía (47) fueron diagnósticas. Así mismo, las biopsias de masas (24), nódulos (17) e incluso de infiltración difusa (16) del peritoneo-omento permitieron el diagnóstico histológico. La tasa de complicaciones fue del 1,75% (una muerte). Conclusión. La biopsia percutánea con aguja gruesa es una técnica con una alta sensibilidad independientemente de la técnica de imagen empleada como guía de la punción (TC o ecografía) y del tipo de lesión biopsiada (masa, nódulo o infiltración difusa). Es una técnica útil con escasa tasa de complicaciones, aunque a veces pueden ser graves

Objective. To evaluate the diagnostic performance of imaging-guided core needle biopsy of nodules and diffuse infiltration of the omentum or of the peritoneum. Material and methods. We retrospectively evaluated 57 patients who underwent core needle biopsy of the peritoneum or of the omentum between March 2014 and January 2017. We used computed tomography (CT) to plan the biopsy. Biopsies were guided by CT or ultrasonography (US). We classified the results as diagnostic (benign / malignant) or inconclusive (inadequate sample). We calculated the sensitivity, specificity, positive-predictive value, and negative predictive value. We analyzed whether the specimen was diagnostic depending on the imaging technique used (CT or US) and on the type of omental or peritoneal involvement from which the specimen was obtained (mass, nodule, or diffuse involvement). Results. All (100%) the percutaneous biopsies were diagnostic. The sensitivity of the technique was 98.18% and the specificity was 100%. The positive predictive value was 100% and the negative predictive value was 50%. Both the specimens obtained under CT guidance (n=10) and those obtained under US guidance (n=47) were diagnostic. Likewise, biopsies of masses (n=24), of nodules (n=17), and even of diffuse infiltration (n=16) of the peritoneum or omentum enabled the histologic diagnosis. The rate of complications was 1.75% (one death). Conclusion. Percutaneous core needle biopsy has high sensitivity regardless of the imaging technique used to guide the technique (CT or US) and of the type of lesion biopsied (mass, nodule, diffuse infiltration). It is a useful technique with a very low rate of complications, although severe complications can occur

Evisceration following Abdominal Scarification in Neonates.

Invasive traditional practices which are frequently harmful are common in the care of children including neonates in developing countries. We report two cases of evisceration of intra-abdominal viscera in two neonates subjected to abdominal scarification with razor blades following febrile illnesses. The greater omentum and a loop of jejunum, respectively, were eviscerated. Both were successfully managed and discharged home. Consent was obtained from the parents for the use of the photos. These cases highlight the dangers of invasive traditional practices on neonates and the urgent need for enlightenment campaigns as well as enactment of policies to help protect these children in developing countries.

Intrauterine device embedded in omentum of postpartum patient with a markedly retroverted uterus: a case report.

BACKGROUND: The intrauterine device is a popular form of long-acting reversible contraception. Although generally safe, one of the most serious complications of intrauterine device use is uterine perforation. Risk factors for perforation include position of the uterus, force exerted during intrauterine device insertion, postpartum period, and breastfeeding. This case is important and needs to be reported because it highlights the need to assess risk factors for uterine perforation. It adds to the medical literature because it examines the relationship between position of the uterus and the location of uterine perforation. This case report is unusual in that it describes the mechanism and specific location of uterine perforation in relation to the position of the uterus. CASE PRESENTATION: We present a case of an intrauterine device found in the omentum of a 30-year-old white postpartum woman with a significantly retroverted uterus after the intrauterine device threads were not visualized on speculum examination during a 6-week placement check. The intrauterine device was located and removed via laparoscopy without complication. CONCLUSIONS: This case report will be of interest to women's health practitioners because it illustrates the importance of identifying patients with risk factors for uterine perforation, examining the relationship between uterine position and location of perforation. This is especially significant because the true incidence of perforation may be higher than the numbers reported in the literature. There is no specific diagnostic code for uterine perforation and it is unlikely that retrospective studies can accurately identify all cases.

IMAGING DIAGNOSIS-ULTRASOUND UNCOMMON FEATURES OF AN ABDOMINAL GOSSYPIBOMA IN A DOG.

An abdominal mass was incidentally detected in a 12-year-old, neutered female, crossed breed dog. Abdominal ultrasonographic examination showed a well-delineated, irregular, heterogeneous mass that did not generate any distal acoustic shadowing. Transcutaneous US-guided biopsy of the mass were nonconclusive but raised the possibility of neoplasia. Surgery discovered a mass embedded in the omentum and a large quantity of surgical sponges were identified in cut section. To the authors' knowledge, this represents the first published case of gossypiboma casting no characteristic distal acoustic shadowing.

[Skret sieci wiekszej jako przyczyna dolegliwosci bólowych miednicy mniejszej u pacjentki po cieciu cesarskim - trudnosci diagnostyczne]. / Skret sieci wiekszej jako przyczyna dolegliwosci bólowych miednicy mniejszej u pacjentki po cieciu cesarskim - trudnosci diagnostyczne

Spontaneous torsion of the greater omentum is a rare cause of the acute abdomen or pain complaints of the pelvis minor. It can imitate an severe inflammatory conditions rolling in the peritoneal cavity like e.g. appendicitis. At the work a case of omental torsion at the patient after the caesarean section with pain problems in the right iliac fossa was presented. Problems of the preoperative diagnostic testing and a possible differential diagnosis were discussed.

Trocar in conventional laparoscopic and robotic-assisted surgery as a major cause of iatrogenic trauma to the patient.

All laparoscopic procedures, laparoscopic or robotic-assisted, start with a trocar entry. Unfortunately unknown to most, this is an extremely important part of the surgery, as 80% of major vascular injuries and 50% of intestinal injuries occur during this procedure. Laparoscopic first entry is often delegated to trainees with little experience, wrongly assuming that laparoscopic entry is similar to incisional entry at laparotomy. This may result in patient death (mortality of major vascular injuries is 11% and unrecognized intestinal injuries is 5%) or significant temporary or permanent morbidity.

Gastric perforation due to foreign body ingestion mimicking acute cholecystitis.

An 82-year-old man presented with signs and symptoms that were suggestive of acute cholecystitis. He underwent a laparoscopic cholecystectomy. During the intervention, a wooden foreign body was removed from the infiltrated omentum, probably after it had perforated the gastric antrum. The gastric perforation had led to a secondary infection of the gallbladder. The presumed gastric perforation was treated conservatively, and the patient recovered well and was discharged after 7 days. Secondary inflamed gallbladders are rare; the current case is, to the best of our knowledge, the first case reporting a secondary infection of the gallbladder due to a gastric perforation. Clinicians should be aware of possible ingestion of foreign bodies in elderly patients wearing dental prosthetic devices.

BWH emergency radiology-surgical correlation: omental hematoma with active extravasation: a rare diagnosis.

We describe the radiological and intraoperative correlation of a large omental hematoma with active intra-abdominal bleeding secondary to omental lacerations in a 75-year-old man following blunt trauma from a motor vehicle accident. The purpose of this article is to emphasize the importance of recognizing omental and mesenteric injuries in trauma patients, as these injuries are rare and can be overlooked on CT.

Involvement of transforming growth factor-ß3 and betaglycan in the cytoarchitecture of postoperative omental adhesions.

BACKGROUND: Adhesions commonly appear in patients after abdominal surgery, with considerable individual variation in adhesion composition and severity of the repair process. Here, we address the influence of transforming growth factor (TGF)-ß3 and betaglycan in this response, in relation to TGF-ß1, in an adhesiogenic rabbit model. MATERIALS AND METHODS: Omental adhesions were recovered 3, 7, 14, and 90 d after the implantation of a polypropylene mesh on the parietal peritoneum in New Zealand White rabbits. Omentum from nonoperated animals served as control. Tissue specimens were examined for TGF-ß3 and TGF-ß1 (Western blotting, reverse transcription-polymerase chain reaction), and TGF-ß1:TGF-ß3 messenger RNA and protein expression ratios were analyzed. Immunohistochemical detection of TGF-ß3 and betaglycan was performed. RESULTS: Injury to the omentum led to mobilization of TGF-ß3 and betaglycan-expressing cells from milky spots. Fibrous zones in adhesions were simultaneous to the presence of TGF-ß1 and the membrane-bound form of betaglycan (7-d adhesions), whereas soluble betaglycan appeared in TGF-ß1-positive areas showing limited fibrosis (3-d adhesions). The elevated expression of TGF-ß3 concurrent with the presence of membrane-bound form of betaglycan was observed in zones of adipose regeneration (14-d adhesions), whereas zones of fibrous consistency were negative for TGF-ß3. CONCLUSIONS: Milky spots on the omentum contain inflammatory/immune cells positive for TGF-ß3, TGF-ß1, and betaglycan, playing a role in the damaged omentum repair. Our observations support the contribution of TGF-ß3 to tissue repair through adipose tissue regeneration and the profibrotic role of TGF-ß1 and suggest that these effects on the local wound repair response could be driven by the expression of betaglycan in its soluble or membrane-bound form.

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre.

INTRODUCTION: The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms. METHODOLOGY: A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study. RESULTS: A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries. CONCLUSION: We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.