İsmail Arslan

A novel laparoscopic suction device for applying precise aspiration during laparoscopic surgery: sponge-tip suction tube.

Aspiration of the intra-abdominal fluid and debris is usually needed during different stages of the operation. This is necessary to protect the intra-abdominal space from contamination and/or to remove blood or tissue fluids occurring during the operation. It is also essential for obtaining a clean surgical area. Aspiration of the intra-abdominal fluid is relatively more difficult in laparoscopic surgery because of the suctioning of the omentum and intestine with the aspirator. In this paper, we report on a new suction device (sponge tip suction tube; STST), which allows the surgeon easier suctioning of intra-abdominal fluid. STST has an additional sponge tip and air channel, which prevents the device from suctioning intra-abdominal organs, such as the intestine and omentum. We tested the efficacy of STST in a simulated intra-abdominal space, such as a large transparent plastic bag with fresh sheep intestine-omentum and with 2000 cc of physiologic saline solution and 14 mm Hg of air pressure. Whereas the suctioning of all the fluid was difficult and time consuming when the conventional suction unit was used, all of the saline solution was easily and quickly suctioned when STST was used. In conclusion, STST provides a safe, fast, and complete fluid extraction.

Hepatocellular carcinoma in the common bile duct “Hepatocellular Carcinoma”

To the editor: Hepatocellular carcinoma (HCC) is the most common primary epithelial tumor of the liver that originates from hepatocytes. It has been stated that cirrhosis is a predisposing factor for development of HCC as 80% of the cases are associated with cirrhosis (1). Some sporadic HCC cases arising from extrahepatic tissue mostly localized around the liver parenchyma or biliary system have also been reported (2). Here, we present a HCC first diagnosed in the extrahepatic bile ducts causing obstructive jaundice. A 75-year-old male patient was admitted to our hospital with complaints of epigastric fullness, pain, nausea, vomiting and dark-yellowish urine for one week. Except for alcoholism, his medical history was uneventful. During the physical examination, a mild hepatomegaly was noted exceeding the right costal margin nearly 2 cm with remarkable splenomegaly. Blood tests revealed direct bilirubine 1.77 mg/dl (0.1–0.2 mg/dl), indirect bilirubine: 2.88 mg/dl (0.2– 0.8 mg/dl), AST: 51(5–40 U/l), ALT: 27(5–40 U/l), ALP: 312(38–155 U/l), GGT: 95(10–49 U/l), AFP: 0 (o 11.3 IU/l), CA-19-9: 240(o 39 U/ml). The other blood test results were within normal limits. Contrastenhanced CT and US of the abdomen showed dilated intrahepatic bile ducts, splenomegaly and dysmorphic liver with no mass. ERCP revealed a 1.5–2 cm mass occluding almost completely the common hepatic duct just below the hilar bifurcation. The main bile duct was normal in shape and diameter. Several biopsy materials were collected, which failed to identify malignancy. On laparotomy, intraoperative USG showed slightly diffuse dilation of intrahepatic bile ducts, but no tumoral lesion within the liver. Meanwhile a hyperechoic lesion without posterior shadow was noted at the hilar bifurcation. Upon examination, no continuation could be noted between the lesion described with USG and the main liver. Patient was given an extrahepatic bile duct exploration, and a 20 15 mm polypoid mass with 0.6 mm pedicle at the bifurcation of the right and left extrahepatic bile ducts was detected (Fig. 1). The main bile duct was resected over a Roux-en-Y hepaticojejunostomy. Postoperative histological examination of the resected materials revealed a tumor consisting of atypical hepatocytes with moderate polymorphism and mitosis and any normal hepatocyte (Fig. 2). Any normal liver architecture has been reported. Immunohistochemistry examination of the mass showed that tumor cells were not stained with CK7, CK20, chromogranin, AFP and CEA but had weak membranous immunoreactivity with CD10. Patient was diagnosed as having HCC arising from extrahepatic origin, which was localized in the common bile duct. Patient was discharged on the 10th postoperative day and was asked to come back every three months for a checkup. In the sixth postoperative month, the patient was readmitted with clinical deterioration, massive ascites and dyspnea. Liver failure findings were apparent with multiple intraparenchymal lesions in the liver detected with CT (Fig. 3). The patient died due to decompensation of his hepatic failure on the 10th day after his second admission. HCC is a primary epithelial liver malignancy, which usually arises from intrahepatic hepatocytes. Accompanying cirrhosis, major vascular or biliary invasion and extrahepatic lymph node metastasis most often indicate a poor prognosis. Biliary invasion usually leads to tumor migration and obstruction of the main bile ducts. Icteric-type HCC is a clinical condition, first described in 1975 by Tanoue and colleagues (3, 4), which is initially characterized by jaundice resulting from either invasion or compression of the primary tumor to the bile duct wall (5). This group of patients also has primary tumor focus in the mother liver that can be shown with conventional diagnostic tests. Patients with invaded bile ducts and jaundice are usually admitted with a significantly high a-fetoprotein (AFP) level and severe cholangitis (6). Ectopic liver tissue (ELT) is a very rare condition, which is usually diagnosed using laparoscopy, laparotomy or autopsy. Incidence has been given as 0.47% in a laparoscopy series. Arakawa and colleagues (2, 7, 8) reported 22 patients with HCC in the ELT in 1999 with an additional three cases reported after that Arakawa et al. (2) have claimed that even if ELT had its own biliary and portal system, lack of the drainage

A rare localization of giant symplastic leiomyoma: Perianal region

Giant symplastic leiomyoma of the gluteal region is a rarely seen situation. It is accepted as a benign illness. A 36-year- old woman presented to general surgery clinic because of a mass on her right thigh. On physical examination, there was a 7 x 6 cm mass that was mobile and bulging up from the surface of skin, 3 cm from her anus. Pathologic examination revealed symplastic leiomyoma. Leiomyomas are benign smooth muscle tumors. After excision, dermal lesions have a 40% recurrence rate. Even if mitotic activity can be shown microscopically, follow-up is important and unnecessary treatment for symplastic leiomyoma must be avoided.