Hiroyuki Tanishima

A Wound Protector Shields Incision Sites from Bacterial Invasion

BACKGROUND Superficial surgical site infection (SSI) can be caused by bacterial invasion during surgery. We investigated whether bacteria are found at the wound margin during surgery and whether a wound protector (WP; Alexis® Wound Retractor; Applied Medical, Rancho Santa Margarita, CA) contributes to preventing invasion of the incision margin. METHODS We studied 272 patients who underwent gastrointestinal surgery (115 gastric, 157 colorectal, including emergency operations) between October 2005 and July 2007. The WP was used in all operations. After the intra-abdominal procedures were complete, bacterial swabs were taken from the abdominal cavity side of the WP and from the incision margin and used to prepare smears and cultures. After the swabbing, peritoneal lavage was performed using 3,000-5,000 mL of physiologic saline, and, after suture of the fascia, 500-1,000 mL of physiologic saline was used to irrigate the subcutaneous tissue. RESULTS Nine gastric surgery patients and 15 colorectal surgery patients had positive cultures from the abdominal cavity. No patients had positive cultures from the incision margin. Of the 24 patients with positive cultures, three suffered SSIs, all of whom had undergone colorectal surgery. Of the patients who had negative cultures, SSI occurred in only one patient, who had undergone colorectal surgery. CONCLUSIONS These results suggest that the WP protects an incision site from bacterial invasion.

Incarceration of a colonoscope in an inguinal hernia and laparoscopic findings

Incarceration in an inguinal hernia is a rare complication of colonoscopy. We report a case of left-sided inguinal hernial incarceration of the colonoscope and laparoscopic findings. An 83-year-old man was referred to our hospital for surgical treatment of gastric cancer. Physical examination revealed a large inguinal hernia on his left side. Because he complained of hematochezia, colonoscopy was carried out. When the tip reached the splenic flexure, we attempted to straighten the sigmoid colon; however, it became difficult to advance or withdraw the colonoscope because of the resistance and the patient’s pain. Fluoroscopy showed that the sigmoid colon containing the colonoscope was trapped in the left inguinal hernia (Fig. 1). On examination, irreducible inguinal hernia was noted and a loop of the colonoscope was palpable within it. After sedation, we pushed the bulge gently back while maintaining the shape of the loop, without withdrawing the colonoscope, and were able to reduce the incarceration. At the beginning of total gastrectomy, laparoscopic examination was carried out. The examination revealed an indirect inguinal hernia on the left side (Fig. 2a). The content of the hernia was sigmoid colon, which easily exited by changing to the Trendelenburg position. Adhesion was detected between the sigmoid colon and the hernial sac (Fig. 2b). The size of the defect and the stiffness and diameter of the colonoscope have been reported as factors in the development of incarceration; moreover, laparoscopic findings are very useful to explain other mechanisms. The adhesion became a pivot point, and the sigmoid colon easily entered into the hernial sac by changing to the head-up position. We assume that this adhesion allowed the colonoscope to progress toward the descending colon, thereby forming a loop within the hernial sac and, when withdrawing, to increase the hernial orifice and not reduce the loop. Hiroyuki Tanishima, Yoshiharu Shono, Satoru Sakaguchi, Koji Tamagawa, Koichiro Ishida, Toshiji Tominaga, Takehiro Tsujimoto, Masamichi Kimura, Taichi Tatsubayashi and Tetsuya Horiuchi Department of Surgery, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, Japan

Two Case Reports of Resectable Cancer in the Remnant Pancreas after Pancreatectomy for Invasive Ductal Carcinoma of the Pancreas

Introduction: Pancreatic cancer has an extremely poor prognosis. There are several reports on resectable cancer in the remnant pancreas after pancreatectomy; however, few have compared K-ras mutation patterns to clarify recurrent or second primary cancers. Case presentations: Here, we report on two cases of cancer in the remnant pancreas after total pancreatectomy for invasive ductal carcinoma. Case 1: A 56-year-old man underwent pancreaticoduodenectomy for cancer of the pancreatic head. However, serum carbohydrate antigen (CA19-9) was again elevated 23 months later. A tumor in the pancreatic tail was detected on abdominal computed tomography (CT) and total pancreatectomy was performed. Histological examination of the tumors from both operations revealed moderately differentiated adenocarcinoma and the surgical margins of both resected specimens were free of cancerous cells. The K-ras gene mutation was detected at codon 12V of exon 1 in both cancers. Case 2: A 72-year-old woman underwent distal pancreatec...

Laparoscopic colectomy for a patient with congenital renal agenesis

We present a very rare case of laparoscopic colectomy for a patient with ascending colon cancer and an agenetic right kidney. A 57-year-old man visited our institute for further evaluation for a positive fecal occult blood test. Approximately, 20 years earlier, the right kidney of the patient was found to be congenitally absent. A physical examination indicated no anatomical anomalies in his genitourinary system, and the renal function was within the normal range. Total colonoscopy revealed a cancer of the ascending colon and laparoscopic colectomy was performed. The right colon was mobilized by lateral-to-medial extension of a retroperitoneal dissection between the fusion fascia and the anterior renal fascia. The right testicular vessels were preserved without injury to the anterior renal fascia; however, the right ureter could not be detected. The operation was performed safely. Thus, we believe that in patients with congenital unilateral renal agenesis, the anterior renal fascia is present, and laparoscopic ipsilateral colectomy can be safely performed in such patients.