Mohan Narasimhan

Laparoscopic management of post-cholecystectomy sectoral artery pseudoaneurysm.

Vascular injuries during laparoscopic cholecystectomy can occur similar to biliary injuries and mostly represented by intraoperative bleeding. Hepatic artery system pseudoaneurysm are rare. It occurs in the early or late postoperative course. Patients present with pallor, signs of haemobillia and altered liver function. We report a case of right posterior sectoral artery pseudoaneurysm detected 2 weeks after laparoscopic cholecystectomy and successfully repaired laparoscopically. We also describe how laparoscopic pringle clamping saved the conversion. The actively bleeding right posterior sectoral artery pseudoaneurysm was diagnosed by CT angiogram. Embolisation, usually the treatment of choice, would have risked liver insufficiency as hepatic artery proper was at risk because the origin the bleeding artery was just after its bifurcation. Isolated right hepatic artery embolisation can also cause hepatic insufficiency. To our knowledge this is the first reported case of laparoscopic repair of post-laparoscopic cholecystectomy bleeding sectoral artery pseudoaneurysm.

Laparoscopic correction of intestinal malrotation in adult

Intestinal malrotation is rare in adults. Patients may present with acute obstruction or chronic abdominal pain. These symptoms are caused by Ladds bands and narrow mesentery resulting from incomplete gut rotation. Barium, computed tomography (CT) and magnetic resonance imaging (MRI), angiography and sometimes explorative laparotomy are used for diagnosis. Ladds procedure is the treatment of choice but data about laparoscopic approach in adult is scarce. We report three cases of laparoscopic correction of adult malrotation presenting with chronic abdominal pain. The diagnosis is made by CT/MRI. Laparoscopic Ladds procedure (release of bands, broadening of mesentery and appendicectomy) was performed via three ports. Procedure time 25-45 min. All patients were discharged on postoperative day 2. At 6 month follow-up, all are symptom free. Laparoscopic Ladds procedure is an acceptable alternative to the open technique in treating chronic symptoms of intestinal malrotation in adults.

Zenker’s diverticulum

Zenker’s diverticulum is an outpouching of the mucosa through a potential weakness in the posterior pharyngeal wall. Affected individuals are usually men in their seventh or eighth decades and present with dysphagia, regurgitation of undigested food, halitosis, aspiration pneumonia or a swelling in the left side of the neck with a gurgling sound on palpation [1]. A 65-year-old lady recently presented with difficulty in swallowing and regurgitation of food for 6 months. The endoscopy done showed a blind pouch with vegetable material (Fig. 1a) at the level of cricopharynx, anteriorly displaced esophageal lumen proper (Fig. 1b) with a septum in-between, suggestive of Zenker’s diverticulum, confirmed on a barium esophagogram (Fig.1c). The diagnosis of Zenker’s is usually confirmed using a barium esophagogram. Endoscopy is associated with a risk of perforation in an unsuspected diverticulum as its opening is most often aligned in the pharyngeal axis. Hence, intubation of the esophagus should be done gently, under direct vision or using a guide wire. Patients who are symptomatic may be treated by surgery or a minimally invasive endoscopic approach [1].

A Rare Case of Childhood Undifferentiated Embryonal Sarcoma of the Liver Managed Successfully.

A 13-year-old boy presented with low-grade fever, upper abdominal pain, loss of appetite, and weight loss for 2 months, with a history of swelling in his upper abdomen for 15 days. On examination, a 17 x 20-cm intraabdominal, smooth, firm, non-tender swelling was noted occupying epigastric and left hypochondrium. The mass moved with respiration, and finger insinuation between mass and right coastal margin was not possible. There was no ascites and further examination was unremarkable. Liver function tests and α-fetoprotein were normal.