Metin Ertem

Laparoscopic Approach to Hepatic Hydatid Disease

Background: The aim of this paper is to present our brief experience on laparoscopic hydatid cyst surgery; we estimated the reproducibility of used techniques in conventional surgery with this relatively recent and attractive method. Methods: Fifteen cysts in 12 selected hydatid disease patients were treated laparoscopically. Cystotomy, partial cystectomy and drainage were performed in 9 patients. Omentoplasty was added to the procedure in the remaining 3 cases. Results: The mean postoperative hospital stay was 4.9 days. There was no mortality, and 1 patient developed bile leakage. Mean follow-up is 18 months. No recurrence was observed during this period. Conclusion: We suggest that laparoscopic treatment of hydatid disease is feasible in selected patients respecting the principles of open surgery and seems beneficial concerning postoperative comfort, hospital stay and return to daily activities.

Evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy.

Purpose In this study, the effects of intravenous paracetamol treatment on early postoperative period analgesia and recovery characteristics after laparoscopic cholecystectomy have been evaluated. Methods Forty patients whose American Society of Anesthesiologists physical status I or II underwent laparoscopic cholecystectomy and randomly divided into 2 equal groups. In the first group, 1 g paracetamol was given to the patients intravenously after intubation before start of the surgery in 15 minutes. The 100 mL 0.9% NaCl was infused intravenously for the control group in 15 minutes. Postoperative pain was evaluated and recovery characteristics were evaluated. Results Verbal and visual pain scores of the paracetamol group were significantly lower than control group (P<0.05). First morphine requirement and total administered morphine dose and duration of staying in recovery room were significantly decreased in the paracetamol group (P<0.05). Conclusions Beside its effective analgesic properties, paracetamol administration during per operative period supports effective and faster recovery.

Thoracoscopic enucleation of a giant submucosal tumor of the esophagus.

Since the introduction of thoracoscopy in the surgical field, many thoracic interventions have been considered feasible via thoracoscopic route. The authors reported a case of thoracoscopic enucleation of a giant esophageal submucosal tumor (8.5 cm in diameter) situated along the left side of the midesophagus. Histopathologic evaluation revealed a gastrointestinal stromal tumor (GIST). Postoperative period was uneventful and the patient was discharged on the eighth postoperative day. Given the well-known advantages of minimally invasive surgery, we assume that the removal of esophageal submucosal tumors can first be attempted by thoracoscopic approach, even if the tumor is of a big size. In cases of histopathologically unknown tumors preoperatively, definitive examination of the complete specimen provides the basis for further therapeutic decisions.

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.

The Use of Tacker and Arthroscopy Cannules in SILS Cholecystectomy

BACKGROUND The invasiveness of laparoscopic cholecystectomy was further minimized by reducing the number of incisions with the introduction of single-incision laparoscopic surgery (SILS) cholecystectomy. In order to solve the challenges posed by SILS cholecystectomy, an increasing number of techniques have been reported with the advent of new surgical instruments and refinements to existing technology. We describe, in this article, two new techniques that utilize existing instrumentations: an access and a retraction technique. METHODS A consecutive series of 23 selected patients with symptomatic cholelithiasis underwent SILS cholecystectomy from April 10, 2009 to August 12, 2009. The overall procedure was similar to SILS cholecystectomy described in the literature. Hovewer, the access technique, with small-size arthroscopy cannules, was used to overcome the technical difficulty resulting from the collision of large-size caps of the laparoscopy trocars, and the retraction technique with a tacker was used to suspend the fundus of the gallbladder without taking the risk of gallbladder perforation. RESULTS All patients were female, and the mean age was 34 years (range, 27-65). The body mass index of all patients was below 30 kg/m(2). The use of arthroscopy cannules provided a wider range of movement, and the retraction of the gallbladder was achieved safely with the tacker. These techniques reduced the operative times considerably. CONCLUSIONS Most of the challenges posed by SILS cholecystectomy can be easily solved with simple technical modifications.

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.

Single port totally extraperitoneal (STEP) hernia repair: improving the benefits of one-day surgery setting

Single-port laparoscopic surgery is one of the emerging technologies popularizing in all the fields of abdominal surgery. Since single-port technique is firstly applied to laparoscopic totally extraperitoneal (TEP) inguinal hernia repair [1], this operative technique has been improved by experts from all over the world [2, 3]. While basic principles were similar, there are some nuances between the described operative techniques. Homemade or artificial ports may be used in single-port TEP (STEP) to keep the air in surgical field by fixing laparoendocopic instrument in a panel [2–4]. In practice, we insert the single port (SILS port, Covidien, Dublin, Ireland) with help of a Kelly clamp after cutting the inferior edges of the port (Fig. 1). This manoeuvre eases insertion of the port through a 2-cm infraumbilical horizontal incision. The rectal muscle is retracted after cutting the anterior sheet of the fascia. A balloon trocar is used to create an extraperitoneal space under the abdominal wall. No air leak was observed from the port site during the surgery so far. A 5-mm straight laparoscope is used for visualization. A 5-mm grasper and a 5-mm endoscopic scissors are used for dissection. A nonabsorbable synthetic mesh is preferred for hernia repair. Mesh is inserted through a 5-mm port site. Other operative steps are similar with the previous reports [3]. To date, we operated twelve male patients with STEP technique for the treatment of direct inguinal hernia. Bilateral hernia repair was performed in two patients. Median body mass index of the patients was 28 kg/m (24–31). Median operating time was 29 (25–65) min. Median age of the patients was 54 (46–67). All the patients stayed at the hospital less than 24 h, and they were discharged uneventfully with no complication. In our initial experience, we noticed two important benefits of the single-port approach. Firstly, single-port access prevents any complications and unnecessary dissections related with secondary port insertion. Since STEP is a single incision procedure, surgeon does not waste time for another port insertion and port site closure. Secondly, none of our patients stayed longer than 18 h after operation. Their postoperative conditions were suitable to discharge at the same day with surgery. Since these patients were our initial cases, we prefer an overnight observation in hospital. Postoperative hospital stay which is less than 24 h is described as ‘‘one-day surgery setting’’ [5]. STEP for inguinal hernia repair may improve postoperative recovery by reducing surgical trauma and shorten operating time. With the increased operative experience on STEP, inguinal hernia repair may be considered as a day-case surgery (discharge at the same day with surgery) rather than a one-day surgery. This comment refers to the article available at doi:10.1007/s10029012-0917-2.

Foreign body: A sewing needle migrating from the gastrointestinal tract to pancreas

Of all ingested foreign bodies, 2.4% comprise of sewing needles. Through perforation of gastrointestinal tract, which occurs in 1% of cases, they can migrate into the liver and pancreas. Foreign bodies in pancreas should be considered in the differential diagnosis of chronic abdominal pain. Computed tomography scans provide valuable information for the localization of the lesion, which guide the surgeon during the operation. Secondary to foreign bodies that migrate to the pancreas, complications with high mortality such as pancreatitis, pseudoaneurysm, and pancreas abscess can be seen. Thus, for this patient group, diagnostic laparoscopy is recommended, considering its advantages of decreased postoperative pain, decreased wound infection, and faster recovery time. Here we present a case of a 23-year-old female patient, from whom an ingested needle that migrated from the back wall of the stomach to the pancreas was extracted by laparoscopic surgery.