Josip Baković

Synchronous laparoscopic treatment of liver hydatid cysts and cholelithiasis after obstructive icterus

BACKGROUND: Hydatid disease is a parasitic infection caused by Echinococcus granulosus, and the most frequently affected organ is the liver. The laparoscopic approach to liver echinococcosis represents a last frontier in surgical treatment. CASE REPORT: A 58-year old female patient was admitted in hospital due to jaundice and pain in right upper quadrant. Lab findings show leucocytosis and high bilirubin level. US revealed choledocholithiasis with mild dilatation of intra and extrahepatic bile ducts. US also revealed two cysts in II and III liver segment with suspicion on hydatid disease, one 4 cm in diameter and second 2 cm. Bile stone and sladge were removed by ERCP. ERCP did not show communication between cysts and bile ducts. MSCT confirm hydatid cysts in II and III liver segment. Serology tests were negative. The patient recived albendazol during the one month. After albendazol therapy we performed a synchronous laparoscopic cholecistectomy and extirpation of both hydatid cysts. The patient recovered with no postoperative complications. Shortly after she was dismissed from hospital. CONCLUSION: Laparoscopy represents an excellent approach for the treatment of hydatid cyst of the liver in selected patients.Introduction: The recent discovery of enhanced glucose tolerance following bariatric surgery has sparked renewed interest in investigation of unchartered underlying pathways of glucose homeostasis. It is hoped that delineation of the active pathway effected by bariatric surgery may be the first step in the creation of a novel therapy that could be applied to the non-obese type II diabetics as well. Mice provide the optimal model to investigate this physiologic pathway because of the wide availability of genetically-modified mice. However, creation of a bariatric mouse model has proven to be challenging because of the technical complexity and formidable nature of this surgery coupled with the natural fragility of these small rodents. We have created a sleeve gastrectomy mouse model using a simplified technique to study the effects of bariatric surgery on glucose tolerance and beta cell proliferation. Herein, we describe the surgical technique data collected pertaining to the effects of surgery on pattern of weight loss, serum glucose, serum insulin and beta cell proliferation. Methods: 19 mice were randomized to undergo either sleeve gastrectomy(SG) (9) or sham operation(SH) (10). Weight and serum glucose were measured 3 times weekly and serum insulin measurement and pancreatic harvest were performed at the time of sacrifice. Five mice from each group were sacrificed after 1 week and the remainder were sacrificed after 1 month. Results: Survival was 100%. The SG group demonstrated an initial drop in weight and serum glucose as compared to SH, which normalized by 1 month following surgery. SG mice demonstrated significant gastric reexpansion following surgery, often returning to approximately original size after 1 month. Pancreatic analysis demonstrated no significant differences in beta cell proliferation between the two groups after 1 week or 1 month. Conclusion: The simplified sleeve gastrectomy technique is an effective tool to investigate glucose tolerance, weight loss, and pancreatic islet effects of bariatric surgery in a genetically tractable organism. Normalization of glucose and weight in the SG group may be related to noted gastric re-expansion following surgery.

Complications in laparoscopic and open colorectal resections: a single surgeon experience

Cutaneous abdominal metastasis from a primary lung tumour conveys a poor prognosis. Abdominal wall reconstruction following tumour resection usually involves construction of a myocutaneous flap, creating significant risk of hernia formation and increasing morbidity in the palliative patient. In the presented patient, loss of cutaneous continuity due to metastatic tumour and subsequent radiotherapy resulted in a contaminated operating field. As an alternative to a myocutaneous flap, a biological mesh was laparoscopically placed deep to the abdominal wall resection defect, providing reinforcement and reducing the risk of prosthesis infection. Split skin grafting from a right thigh donor site was then performed. To our knowledge, this is the first reported laparoscopic mesh placement for the prevention of ventral hernia formation following abdominal wall lung cancer metastasis resection. It provides a quick, low morbidity alternative to more extensive abdominal wall reconstruction enabling faster discharge from hospital. P002 – Abdominal Cavity and Abdominal WallAim: Laparoscopic splenectomy presents a challenge in patients with splenomegaly despite being the preferred procedure for most elective splenectomies. Our experience with laparoscopic splenectomy in the setting of splenomegaly is presented. Methods: The data were collected prospectively from May 2003. to October 2011. in 39 patients that underwent LS in Clinical Hospital “Dubrava” Zagreb, Croatia. The nature of disease, spleen size (measured on CT or ultrasound), gender, age, op time, conversion, hospital stay, need for accessory incision, type of splenic artery ligation preoperative and postoperative platelet values were recorded. The impact of diagnosis (benign/malignant) and the spleen size onto the outcome following LS in seven years period were evaluated. Results: Majority of patients submitted to LS had benign hematologic disease (30 of 39) and more than half of them had splenomegaly (23/39). Majority of patients with splenic malignancy have splenomegaly (8 of 9). The mean spleen size in splenomegaly patients was 23, 88 cm (range 15-31 cm). Splenomegaly was associated with higher conversion rate (3 vs 2) due to bleeding and longer mean operative time (128, 54 vs 104, 75 min). Furthermore, in splenomegaly more patients required accessory incision and additional port (7 vs 1) and blood transfusion (8 vs 1). But length of stay and postoperative morbidity was not associated with enlarged spleen in our series. Conclusion: According to our results, the same as to some previously presented studies LS has become a treatment of choice for majority of patients including those with splenomegaly. In spite of longer operative time and more blood loss laparoscopic splenectomy in the setting of splenomegaly is safe in appropriately experienced hands with full awareness of increased complexity of technical performance and caution requirement.

Laparoscopic splenectomy in patients with splenomegaly-tendency or contraindication?

Cutaneous abdominal metastasis from a primary lung tumour conveys a poor prognosis. Abdominal wall reconstruction following tumour resection usually involves construction of a myocutaneous flap, creating significant risk of hernia formation and increasing morbidity in the palliative patient. In the presented patient, loss of cutaneous continuity due to metastatic tumour and subsequent radiotherapy resulted in a contaminated operating field. As an alternative to a myocutaneous flap, a biological mesh was laparoscopically placed deep to the abdominal wall resection defect, providing reinforcement and reducing the risk of prosthesis infection. Split skin grafting from a right thigh donor site was then performed. To our knowledge, this is the first reported laparoscopic mesh placement for the prevention of ventral hernia formation following abdominal wall lung cancer metastasis resection. It provides a quick, low morbidity alternative to more extensive abdominal wall reconstruction enabling faster discharge from hospital. P002 – Abdominal Cavity and Abdominal WallAim: Laparoscopic splenectomy presents a challenge in patients with splenomegaly despite being the preferred procedure for most elective splenectomies. Our experience with laparoscopic splenectomy in the setting of splenomegaly is presented. Methods: The data were collected prospectively from May 2003. to October 2011. in 39 patients that underwent LS in Clinical Hospital “Dubrava” Zagreb, Croatia. The nature of disease, spleen size (measured on CT or ultrasound), gender, age, op time, conversion, hospital stay, need for accessory incision, type of splenic artery ligation preoperative and postoperative platelet values were recorded. The impact of diagnosis (benign/malignant) and the spleen size onto the outcome following LS in seven years period were evaluated. Results: Majority of patients submitted to LS had benign hematologic disease (30 of 39) and more than half of them had splenomegaly (23/39). Majority of patients with splenic malignancy have splenomegaly (8 of 9). The mean spleen size in splenomegaly patients was 23, 88 cm (range 15-31 cm). Splenomegaly was associated with higher conversion rate (3 vs 2) due to bleeding and longer mean operative time (128, 54 vs 104, 75 min). Furthermore, in splenomegaly more patients required accessory incision and additional port (7 vs 1) and blood transfusion (8 vs 1). But length of stay and postoperative morbidity was not associated with enlarged spleen in our series. Conclusion: According to our results, the same as to some previously presented studies LS has become a treatment of choice for majority of patients including those with splenomegaly. In spite of longer operative time and more blood loss laparoscopic splenectomy in the setting of splenomegaly is safe in appropriately experienced hands with full awareness of increased complexity of technical performance and caution requirement.