Daniele Crocetti

Peliosis hepatis: Personal experience and literature review

Peliosis hepatis (PH) is a disease characterized by multiple and small, blood-filled cysts within the parenchymatous organs. PH is a very rare disease, more common in adults, and when it affects the liver, it comes to the surgeons attention only in an extremely urgent situation after the lesions rupture with the resulting hemoperitoneum. This report describes the case of a 29-year-old woman affected by recurring abdominal pain. Computed tomography scans showed a hepatic lesion formed by multiple hypodense areas, which showed an early acquisition of the contrast during the arterial phase. Furthermore, it remained isodense with the remaining parenchyma during the late venous phase. We decided on performing a liver resection of segment VII while avoiding a biopsy for safety reasons. The histopathologic examination confirmed the diagnosis of focal PH. PH should always be considered in the differential diagnosis of hepatic lesions. Clinicians should discuss the possible causes and issues related to the differential diagnosis in addition to the appropriate therapeutic approach. The fortuitous finding of a lesion, potentially compatible with PH, requires elective surgery with diagnostic and therapeutic intents. The main aim is to prevent the risk of a sudden bleeding that, in absence of properly equipped structures, may have a fatal outcome.

Reducing the risk of trocar site hernias.

BACKGROUND Trocar site hernias (TSHs) can affect the outcome of laparoscopic surgery in 0.2–3.1% of cases. Factors influencing the development of TSHs include: the number and diameters of trocars; a peritoneal defect greater than the trocar size; midline insertion; the type of trocar tip; manipulation of the trocar site; methods of entry and closure; operative time; infection at the trocar site. TSHs may have an early or late onset. In early onset TSHs, viscera herniate through the peritoneal defect in the first few days after surgery. In late onset TSHs, the peritoneum remains intact and viscera herniate with the peritoneum. TSHs are usually asymptomatic. Occasionally, they can present with bowel obstruction that necessitates emergency surgery.

Z-entry technique reduces the risk of trocar-site hernias in obese patients

TECHNIQUE We propose a novel ‘Z-entry’ technique to enter the abdominal cavity under direct vision of an optical trocar that (theoretically) can reduce the risk of trocar-site hernias in obese patients. After induction of a pneumoperitoneum through a Veress needle, a 12mm optical trocar system is inserted with a 30° laparoscope. Under direct laparoscopic vision, the trocar is inserted in subcutaneous fat in a perpendicular direction through the anterior rectus muscle sheath (Fig 1A) and then advanced at 45° through the muscular plane (rectus abdominis muscle or flat abdominal muscles; Fig 1B). A distance of 1.5–2cm from the skin incision is obtained, and the abdominal wall is entered at 90° (Fig 1C). The anatomical structures encountered are readily recognisable by the optical trocar system. At the skin incision, the towel clips holding the abdominal wall should be dragged upwards to achieve the correct distance between the two perpendicular openings.