Hakan Gök

AN UNUSUAL CASE IN SURGICAL EMERGENCY: ABDOMINAL COCOON AND ITS LAPAROSCOPIC MANAGEMENT

Small bowel obstruction associated with abdominal cocoon (AC) is a rarely encountered surgical emergency. This condition is characterised by a thick fibrous membrane which encases the small bowel partially or completely. It is usually difficult to be able to make a definitive diagnosis in the presence of obscure clinical and radiological findings. Diagnosis is usually made at laparotomy when the encasement of the small bowel within a cocoon-like sac is visualised. Here, we report on a 29-year-old male patient who presented with acute small bowel obstruction and was eventually diagnosed with AC at laparoscopy. In this case, laparoscopic excision of the fibrous sac and extensive adhesiolysis resulted in complete recovery. Although rare, the diagnosis of AC should be kept in cases of patients with intestinal obstruction combined with relevant imaging findings. Laparoscopy should also be considered for the management of this condition in suitable patients.

Application of advancement flap after loose seton placement: a modified two-stage surgical repair of a transsphincteric anal fistula.

Purpose A number of techniques have been described for the treatment of a transsphincteric anal fistula. In this report, we aimed to introduce a relatively new two-stage technique, application of advancement flap after loose seton placement, to present its technical aspects and to document our results. Methods Included in this retrospective study were 13 patients (10 males, 3 females) with a mean age of 42 years who underwent a two-stage seton and advancement flap surgery for transsphincteric anal fistula between June 2008 and June 2013. In the first stage, a loose seton was placed in the fistula tract, and in the second stage, which was performed three months later, the internal and external orifices were closed with advancement flaps. Results All the patients were discharged on the first postoperative day. The mean follow-up period was 34 months. Only one patient reported anal rigidity and intermittent pain, which was eventually resolved with conservative measures. The mean postoperative Wexner incontinence score was 1. No recurrence or complications were observed, and no further surgical intervention was required during follow-up. Conclusion The two-stage seton and advancement flap technique is very efficient and seems to be a good alternative for the treatment of a transsphincteric anal fistula.

Single Incision Laparoscopic Total Gastrectomy and D2 Lymph Node Dissection for Gastric Cancer Using a Four-Access Single Port: The First Experience

Single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to reduce the invasiveness of laparoscopic surgery. SILS has been frequently applied in various clinical settings, such as cholecystectomy, colectomy, and sleeve gastrectomy. So far, there have been four reports on single incision laparoscopic distal gastrectomy and one report on single incision laparoscopic total gastrectomy with D1 lymph node dissection for gastric cancer. In this report, we present our single incision laparoscopic total gastrectomy with D2 lymph node dissection technique using a four-hole single port (OctoPort) in a patient with gastric cancer.

Relaparoscopic Treatment of Recurrences after Previous Laparoscopic Inguinal Hernia Repair

Background. Relaparoscopic treatment of inguinal hernia recurrences has become a relatively new concept with favourable results. The purpose of this study was to examine a series of relaparoscopic repair, present technical experiences, and the clinical outcomes in this subset of patients. Patients and Methods. The medical records of five patients who underwent relaparoscopic repair (TAPP or TEP) for a recurrence between March 2005 and September 2012 were retrospectively reviewed. Results. All the patients were male with a mean age of 45 years. Technical failures in the previous repairs were the main factors contributing to recurrences. In two re-TEP cases with no previous mesh fixation, the old mesh remained on the peritoneal side during preperitoneal dissection and this greatly facilitated surgical manipulation. The mean operative time was 93 min (range, 45–120 min). There were no conversions, no intraoperative complications, and no morbidity or rerecurrence after a mean follow-up period of 17 months (range, 7–24 months). Conclusion. Relaparoscopic repair appears to be safe and effective in the treatment of recurrent inguinal hernia and repeated TEP could be a simpler approach than expected in the presence of no prior mesh fixation.

Can volumetric measurement be used in the selection of treatment for inguinoscrotal hernias

Objective Inguinoscrotal hernias are often qualified subjectively as big, giant, scrotal, etc. In order to classify this type of hernia, objective criteria are needed. For this purpose, we aimed to introduce a scrotal volume measurement-based classification system and propose a corresponding surgical plan (open or laparoscopic surgery, anterior or posterior repair) based on volumetric data. Material and Methods Between October 2012 and October 2013, 30 consecutive male patients with a mean age of 59.5 years (range: 36 to 82 years) presenting with unilateral ISH were included in this retrospective study. Physical measurements in the upright position and computerized tomography measurements using the Valsalva maneuver were obtained from all patients. Results Of the 30 patients, 26 patients had scrotal volumes less than 1000 mL, two patients had SVs between 1001 and 2000 mL, one patient had an SV between 2001 and 3000 mL, and one patient had an SV greater than 3000 mL. Laparoscopic total extraperitoneal repair was performed in patients with scrotal volumes inferior to 1000 mL. In three patients with scrotal volumes between 1000 and 3000 mL, an open posterior approach was used. In one patient with a scrotal volume superior to 3000 mL, no surgical intervention was performed due to the patients cardiac comorbidity. Conclusion By establishing a common language among surgeons, we believe that the volumetric measurement-based scrotal hernia classification system proposed in this study will lead to further studies on the subject.

Desmoplastic fibroblastoma: an unusual dermal presentation on the buttock of a patient with muscular dystrophy

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Hiatal fıtıklarda yamalı onarım: Cerrahi teknik ve erken dönem sonuçlarımız

GİRİŞ Hiatal fıtıklar çeşitli boyutlarda görülebilmektedir. Endoskopistler tarafından küçük fıtıklar, hiatal yetmezlik veya hiatal gevşeklik veya endoskopinin yeterli kavranmaması şeklinde tarif edilmekte olup sıklıkla mide ve kolon gibi organların torakal boşluğa geçtiği görülmektedir. Hiatal fıtıkların endoskopik olarak tanınması deneyim gerektirmektedir. Endoskopik tanıda gastroözofagial bileşkenin, özofagial orifiste krusların yaptığı bası daralmasının en az 2 cm üzerinde mediastinal boşluğa kaymış olması gerekmektedir. Paraözofagial fıtıklarda ise endoskopun retrofleksiyonunda tanı konulabilmektedir.

Rare complication following Longo operation: giant rectal haematoma. Case report

A rectal haematoma case developing after a Longo operation, which was treated conservatively, is presented. Haemorrhoidectomy performed by the Longo technique is a new treatment option aimed at surgical therapy of the haemorrhoidal disease. Haemorrhoidectomy performed by this technique is preferred by the surgeons and the patients due to lack of pain in the post-operative period; however, complications following haemorrhoidectomy apply to this technique, too. A 36-year-old female patient presented to our hospital with anal bleeding and palpable soft swellings in the anal region. Her physical examination revealed grade III internal haemorrhoidal piles. The patient was operated on with the Longo technique and was discharged from the hospital on post-operative day 1. Three days after discharge, the patient presented to the hospital with complaints of rectal bleeding and frequent defecation. A serious rectal bleeding was observed. A soft mass was palpated at the posterior rectal wall on digital rectal examination which could be consistent with haematoma. The patient was hospitalized because of laboratory findings of Hct 22% and Hb 6.7 g/dL. An intramural homogenous mass that was located next to rectum’s left border, compressing the rectum, which was approximately 7.5 ¥ 7 and 5 ¥ 10 cm in diameter was seen on computed tomography (CT; Figs 1 and 2). Blood transfusion was administered. The patient was discharged without any surgical intervention 4 days later. The dimension of haematoma decreased to 3.8 cm on CT that was performed 7 months later. The control performed approximately 1 year later revealed that the patient’s complaints resolved completely. Different treatment options such as conservative therapy, simple drainage or surgical intervention aimed at managing rectal haematomas are observed to be recommended in the literature. Although bleeding is the most frequent complication of haemorrhoidectomy, rectal haematoma is seen rarely. Detruit et al. reported a haematoma case that occurred on the retrovaginal wall after a Longo operation. Pelvic infection developed after the drainage of haematoma, and the patient was operated on two more times. Conservative therapy was chosen in our case. The most important thing is to decide which treatment option is suitable in such a complication. The conservative approach is an option in such cases.