Akihiro Kawabe

Usefulness of a virtual reality simulator or training box for endoscopic surgery training

This study investigated whether the use of a simulator for endoscopic surgery training improves the performance of actual operations. For the study, 16 medical students were divided into three groups: a virtual reality (VR) simulator group (n = 6), a training box (TB) group (n = 6), and a control group (n = 4). The VR and TB groups received 2 h of training per day for 5 days, after which they were requested to perform intestinal dissection, to close a gastric perforation, and to perform cholecystectomy in pigs. Performance was assessed on the basis of the operating time and the error score. Although there were no differences between the three groups in terms of the total operating time or error score, the VR and TB groups required less time for closure of the gastric perforation than the control group. In addition, the operating time decreased as actual operating experience increased in the VR group. In the TB group, the time for closure of a gastric perforation was shorter when the supervisor had seen the operation before training. These findings demonstrated that a simulator is useful for acquiring psychomotor skills, but does not immediately enable clinical performance of an operation. More actual experience and good supervision are essential for increasing the effectiveness of training with the VR and TB simulators, respectively.

Laparoscopic ultrasonography and operative cholangiography prevent residual common bile duct stones in laparoscopic cholecystectomy.

We retrospectively evaluated the role of intraoperative cholangiography (IOC) combined with laparoscopic intraoperative ultrasonography (LIOU) for detection of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. We reviewed 184 patients with biliary stones. Preoperatively, all patients underwent ultrasonography (US); 183 of the patients were investigated by cholangiography (oral and intravenous cholangiography in 145 and endoscopic retrograde cholangiography in 44). LIOU was carried out in all patients and IOC was done in 183. LIOU visualized the bile duct in 94.6% of the patients and IOC was successful in 95.6%. CBD stones were detected in a total of 17 patients, 9 (52.9%) of whom were positive on preoperative investigations. The sensitivity for detecting CBD stones was 29.4% with US, 22.2% with oral and intravenous cholangiography, 50.0% with endoscopic retrograde cholangiography, 82.4% with LIOU, and 93.3% with IOC. The diameter of the stones visualized intraoperatively (4.4 +/- 1.2 mm) was smaller than that of the stones detected preoperatively (6.9 +/- 2.6 mm). The stones were removed during laparoscopy in 15 patients and after conversion to laparotomy in 2. None of the patients had residual CBD stones after follow-up for 6 to 50 months. Intraoperative examination using both LIOU and IOC was useful for prevention of residual CBD stones.

Ileo-ileal intussusception caused by lymphangioma of the small bowel treated by single-incision laparoscopic-assisted ileal resection

Intraabdominal lymphangiomas are uncommon; additionally, those affecting the gastrointestinal tract are rare and account for less than 1% of cases. Intussusception caused by a cystic lymphangioma of the small bowel is extremely rare. The patient was a 20-year-old woman who visited our emergency room with a complaint of abdominal pain. A computed tomography image revealed ileo-ileal intussusception with a leading hypovascular mass measuring 1 cm in a diameter. Single-incision laparoscopic-assisted ileal resection was performed. The surgical specimen consisted of a soft polycystic mass. Macroscopically, a pedunculated polyp with a convolutional pattern was found. Microscopically, the inner surfaces of the cysts were covered with a single layer of endothelial cells. On immunohistochemical examination, the endothelial cells were partially positive for D2-40 and CD34. Smooth muscle cells were also found around the cysts. The lesion was diagnosed as a cystic lymphangioma. Dozens of cases of small bowel lymphangiomas have previously been reported. Of these, cases with intussusception were very rare. This is the first case of small bowel intussusception due to lymphangioma treated by single-incision laparoscopic-assisted surgery.

Elective laparoscopic repair after reduction might be useful strategy for incarcerated obturator hernia: a case report

Abstract Obturator hernia is a rare clinical condition that causes intestinal obstruction. Recent reports have suggested that laparoscopic repair may be useful for incarcerated obturator hernia in select patients. The patient was a 64-year-old female who presented to our emergency department with a chief complaint of abdominal pain. Computed tomography (CT) imaging revealed an incarcerated obturator hernia on her right side, without apparent findings of irreversible ischaemic change or perforation. She had a previous history of cardiovascular surgery and was taking an anticoagulant medication. We performed a reduction of the incarcerated intestine. After heparin displacement, laparoscopic repair was electively performed. During laparoscopy, an occult obturator hernia was found on the left side. We repaired the bilateral obturator hernia using a mesh prosthesis. Elective laparoscopic repair after reduction might be a useful procedure for incarcerated obturator hernias in those patients without findings of irreversible ischaemic change or perforation.

Torsion of Atypical Meckel’s Diverticulum Treated by Laparoscopic-Assisted Surgery

Introduction Meckels diverticulum (MD) is the most common congenital anomaly of the intestine, with an incidence of 2~4%. Of those, only 2% of patients with MD are symptomatic. Torsion of MD is extremely rare, and only a dozen cases have been previously reported. Case Report The patient was a 49-year-old male who presented to our emergency room with a chief complaint of lower abdominal pain. Computed tomography imaging revealed an irregular polycystic mass connected to the small intestine that measured 7.5 cm in a diameter. A laparoscopic-assisted partial resection of the jejunum was performed. The lesion was found to have caused torsion and was located 130 cm from the ileocecal valve. The specimen was polycystic in appearance and showed communicating links with the submucosal layer of jejunum but not with the lumen. The pathological diagnosis was a torsion of an atypical presentation of MD. Conclusion This case was different from typical cases of MD in that it was located on significantly oral side and had the appearance of polycystic morphology.

Case of reduction en masse who presented with no symptoms: Case of reduction en masse

The early and accurate diagnosis of reduction en masse followed by proper treatment is important but has been difficult. Here, we report the case of a 58‐year‐old Japanese man who presented with abdominal pain and vomiting at a nearby clinic. He was referred to our hospital on suspicion of small bowel obstruction. Despite the total disappearance of his symptoms, the abdominal X‐ray examination showed distended loops of small bowel. The preoperative diagnosis of small bowel strangulation due to an internal hernia was made by CT, and we therefore performed emergency exploratory laparoscopy. We intraoperatively diagnosed the patient with the reduction en masse of a right inguinal hernia, and we conducted a transabdominal preperitoneal hernioplasty. This patients case demonstrates that even when a patient is asymptomatic after the reduction of an inguinal hernia, the possibility of a reduction en masse remains.

Is postponed laparoscopic cholecystectomy justified for acute cholecystitis appearing early after onset?: Postponed laparoscopic cholecystectomy

Early laparoscopic cholecystectomy (ELC) is considered the standard treatment for acute cholecystitis for patients who can tolerate surgery. The ideal time for performing ELC is reported to be 72 h from onset. However, many patients undergo surgery on or after the fourth day from onset, even if they presented early after onset. A few reports have investigated the feasibility and disadvantages of this so‐called “postponed laparoscopic cholecystectomy” (PLC).

Outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis performed at a single institution: Early laparoscopic cholecystectomy

Debate continues regarding the clinical outcomes of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). The aim of this retrospective study was to compare clinical outcomes of ELC and DLC.

Strangulated gallbladder caused by a tip of the omentum attached to the abdominal wall: a case report

Abstract Strangulation of the gallbladder associated with the omentum is extremely rare and, to our knowledge, only two cases have been previously reported. The patient was a 91-year-old female who presented to our emergency room with a chief complaint of upper abdominal pain. Computed tomography imaging revealed a gourd-shaped gallbladder with biphasic appearance divided clearly at the body. In the fundus side, the wall of the gallbladder was oedematous and thickened, while the neck side was intact. On the second day after onset, a laparoscopic cholecystectomy was performed. A tip of the omentum encircling the gallbladder was adhered to the abdominal wall and was strangling the gallbladder. By cutting the omentum at the attachment site, the strangulation was released. Laparoscopic cholecystectomy was performed, and the patient was discharged with an uneventful course. We experienced an extremely rare case of strangulated gallbladder caused by a tip of the omentum attached to the abdominal wall.

Multiple Gastric Gastrointestinal Stromal Tumors in a Patient with Neurofibromatosis Type 1

Gastrointestinal stromal tumors (GISTs) are relatively common in neurofibromatosis type 1 (NF 1) patients. Approximately 90% of GISTs associated with NF 1 are located in the small intestine, while sporadic GISTs are most commonly located in the stomach. Here we report an extremely rare case of an NF 1 patient with multiple gastric GITs (90 or more) but without multiple small intestinal tumors. A 63-year-old female patient who had a history of NF 1 underwent surgery for a gastric neuroendocrine tumor and gastric submucosal tumor (SMT). During the operation, multiple small nodules were identified on the serosal surface of the upper stomach. SMT and multiple nodules on the serosal surface were diagnosed as GISTs consisting of spindle cells positive for KIT, CD34, and DOG-1. Both GIST and the normal gastric mucosa showed no mutations not only in the c-kit gene (exons 8, 9, 11, 13, and 17) but also in the PDGFRA gene (exons 12, 14, and 18). This patient is being followed up without the administration of a tyrosine kinase inhibitor.