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What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations

OBJECTIVE: Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy is still inevitable in certain cases. Knowledge of the rate and impact of the underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decided to review the rate and causes of conversion from laparoscopic to open cholecystectomy. METHOD: This study included all laparoscopic cholecystectomies due to gallstone disease undertaken from May 1999 to June 2010. The exclusion criteria were malignancy and/or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rate of conversion to open cholecystectomy, the underlying reasons for conversion, and postoperative complications were also analyzed. RESULTS: Of 5382 patients for whom LC was attempted, 5164 were included this study. The overall rate of conversion to open cholecystectomy was 3.16% (163 patients). There were 84 male and 79 female patients; the mean age was 52.04 years (range: 26–85). The conversion rates in male and female patients were 5.6% and 2.2%, respectively (p<0.001). The most common reasons for conversion were severe adhesions caused by tissue inflammation (97 patients) and fibrosis of Calots triangle (12 patients). The overall postoperative morbidity rate was found to be 16.3% in patients who were converted to open surgery. CONCLUSION: Male gender was found to be the only statistically significant risk factor for conversion in our series. LC can be safely performed with a conversion rate of less than 5% in all patient groups.

Fournier’s gangrene: Is it scrotal gangrene?

IntroductionFournier’s gangrene was originally described as scrotal gangrene in young males. Today, it is generally accepted as synergistic necrotizing fasciitis of perineal, genital, or perianal regions, and the epidemiologic data have changed. However, there are still limited data about females due to the lack of female patients, even in large case series.MethodsA retrospective review of the medical records of all patients who received surgery for emergency conditions over the past 22 years was performed to identify patients with Fournier’s gangrene. Data from these patients were then reviewed to determine the age, gender, etiology, causative bacteria, predisposing factors, treatment modalities, length of hospital stay, and morbidity and mortality rates associated with Fournier’s gangrene. Data were evaluated using multivariate analyses.ResultsSixty-five patients (20 female) were identified with the diagnosis of Fournier’s gangrene. The mean age was 50.8 years. The most common etiology was hemorrhoidectomy in male and perianal abscess in female patients. The most commonly isolated microorganism in both male and female patients was Escherichia coli. Twenty-nine patients had diabetes mellitus, which was the most common predisposing factor. Mean hospitalization time was 24.4 days and the overall mortality was 27.70%.ConclusionFournier’s gangrene is still an important disease with high mortality rates in spite of the developments in intensive care units and new-generation antibiotics. It seems that there are no major differences between male and female patients in the characteristics of the condition.

Outcome of the patients with chronic mesh infection following open inguinal hernia repair

Purpose Hernia repairs are the most common elective abdominal wall procedures performed by general surgeons. The use of a mesh has become the standard for hernia repair surgery. Herein, we discuss a management strategy for chronic mesh infections following open inguinal hernia repair with onlay prosthetic mesh. Methods In this study, 15 patients with chronic mesh infections following open inguinal hernia repairs were included. The medical records of these patients were retrospectively reviewed and information regarding presentation, type of previous hernia repair, type of mesh, operative findings and bacteriological examination results were obtained. In all cases, the infected mesh was removed completely and the patients were treated with antibiotic regimens and local wound care. Results Fifteen mesh removals due to chronic infection were performed between January 2000 and March 2012. The mean interval of hernia repair to mesh removal was 49 months. All patients were followed up for a median period of 62 months (range, 16 to 115 months). In all patients, the infections were resolved successfully and none were persistent or recurrent. However, one patient developed recurrent hernia and one developed nerve injury. Conclusion Chronic mesh infection following hernia repair mandates removal of the infected mesh, which rarely results in hernia recurrence.

Is there an association between mastalgia and fibromyalgia? Comparing prevalence and symptom severity.

To determine the prevalence of mastalgia in patients with fibromyalgia (FM) and the prevalence of FM in patients with mastalgia in order to investigate coexistence, and to compare the pain patterns in the case of mastalgia or FM alone versus the two in combination. Fifty consecutive patients with mastalgia and 50 consecutive patients with FM were assessed and examined both for the existence and severity of mastalgia and FM. A high proportion of patients with mastalgia (36%) fulfilled the criteria for FM and 42% had mastalgia in the FM group. Two distinctive entities mastalgia and FM, being both unexplained pain syndromes, seem to frequently coexist. Patients with mastalgia or FM should be thoroughly questioned considering each of the diseases so that in case of coexistence an appropriate therapy might be implemented for a successful pain management.

Effects of N-butyl-2-cyanoacrylate on high-level jejunojejunostomy.

Background: Morbidity and mortality due to anastomotic complications in gastrointestinal surgery remain important problems. The tissue adhesive N-butyl-2-cyanoacrylate (NB2CA) is used in many fields of surgery. This study was designed to assess the effects of NB2CA on high-level jejunojejunostomy. Materials and Methods: Forty male albino Wistar rats were divided into 4 groups of 10 each. The groups were treated as follows: group 1 underwent only a jejunojejunostomy, group 2 underwent jejunojejunostomy followed by NB2CA application around the anastomosis, group 3 underwent jejunojejunostomy after a 60-min ischemia and a 60-min reperfusion, and group 4 underwent jejunojejunostomy after a 60-min ischemia and a 60-min reperfusion followed by NB2CA application around the anastomosis. At postoperative day 7, the subjects in all groups were sacrificed. Intra-abdominal adhesions, anastomotic complications and anastomotic burst pressures (ABP) were recorded. Results: The analysis of all the groups for adhesion scores and ABP showed statistical significance (p < 0.001). Conclusions: The use of NB2CA had positive effects in terms of increasing ABP both with and without the initial ischemia- reperfusion insult. However, it had the adverse effect of significantly increasing the number of intra-abdominal adhesions.

Pure Laparoscopic Versus Open Live Donor Nephrectomy: Evaluation of Health Survey and Graft Functions

BACKGROUND Laparoscopic donor nephrectomy (LDN) has become the gold standard in many kidney transplantation centers seeking to increase the number of potential live donors. This study was designed to compare the health surveys and graft functions between LDN and open donor nephrectomy (ODN). METHODS We retrospectively analyzed all patients who underwent donor nephrectomy between December 2005 and September 2009 who had at least 1 year of follow-up. We reviewed demographic data, operative time, warm ischemia period, graft function, and quality of life. RESULTS Among the 132 cases, 98 were pure LDN and 34 were ODN. Demographic data were similar in both groups. Operative times were significantly longer in the ODN group but warm ischemia times significantly longer in the LDN group. However, graft functions were similar in both groups. There was 1 graft loss due to arterial thrombosis of the transplanted kidney among the LDN group. Short-Form 36 health survey scores were similar except for the role-physical subscale. CONCLUSION Although we failed to observe a significant difference between ODN and LDN as far as the quality of life and graft functions were concerned, the previously documented advantages of laparoscopy with similar operative results suggest? LDN to be the gold standard for this procedure in our institution.

Breast hamartoma: a clinicopathologic analysis of 27 cases and a literature review

OBJECTIVES: Breast hamartoma is an uncommon breast tumor that accounts for approximately 4.8% of all benign breast masses. The pathogenesis is still poorly understood and breast hamartoma is not a well-known disorder, so its diagnosis is underestimated by clinicians and pathologists. This study was designed to present our experience with breast hamartoma, along with a literature review. METHOD: We reviewed the demographic data, pathologic analyses and imaging and results of patients diagnosed with breast hamartoma between December 2003 and September 2013. RESULTS: In total, 27 cases of breast hamartoma operated in the Ankara University Medicine Facultys Department of General Surgery were included in the study. All patients were female and the mean age was 41.8±10.8 years. The mean tumor size was 3.9±2.7 cm. Breast ultrasound was performed on all patients before surgery. The most common additional lesion was epithelial hyperplasia (22.2%). Furthermore, lobular carcinoma in situ was identified in one case and invasive ductal carcinoma was observed in another case. Immunohistochemical staining revealed myoid hamartoma in one case (3.7%). CONCLUSION: Breast hamartomas are rare benign lesions that may be underdiagnosed because of the categorization of hamartomas as fibroadenomas by pathologists. Pathologic examinations can show variability from one case to another. Thus, the true incidence may be higher than the literature indicates.

Living-Donor Hepatectomy

BACKGROUND Organ transplantation from deceased donors is still far below the need. Because of this deficiency, liver transplantations are performed mostly from live donors in many transplant centers in our country. Living-donor liver transplantation (LDLT) has evolved dramatically over the past decade. The aim of this study was to present our clinical experience with living-donor hepatectomy. METHODS We retrospectively analyzed all patients who underwent donor hepatectomy between March 2000 and September 2010. We reviewed demographic data, operation type, operation and cold ischemia times, duration of hospital stay, and postoperative complications. RESULTS During the study period, 140 living donors underwent operations for liver transplantation. We performed 108 right hepatectomies, 17 left hepatectomies, and 15 left lateral hepatectomies. The mean age of the donors was 30.8 years. There was no operative or postoperative mortality. Overall morbidity rate was 13.57% (n = 19). Nine patients had biliary leakages, 4 biliomas; 2 urinary tract infections, and 1 each inferior vena caval injury, pneumonia, portal vein thrombosis, and acute tubular necrosis. Reoperation was not required in any of these patients. CONCLUSIONS Living-donor liver transplantation is a valuable alternative for patients awaiting a cadaver organ. Live-donor hepatectomy can be performed with low morbidity. The greatest disadvantage of this procedure is the risk of the surgical operation for the individual who will experience no medical benefit from this procedure.

Single Stapler Technique in Laparoscopic Donor Nephrectomy

BACKGROUND Laparoscopic donor nephrectomy (LDN) is usually performed with at least 2 separate vascular staplers for division of the renal artery and vein. However, we used a single stapler regardless of the number of renal arteries and veins. Furthermore, the graft was quickly retrieved by hand without using an extraction bag using our technique. Herein we have presented our experience with LDN of grafts with single or multiple renal arteries and/or veins using a single stapler and hand removal. METHODS We reviewed demographic data, operative and warm ischemia times, postoperative complications, and graft function. RESULTS Between December 2005 and September 2009, we performed 85 cases with 1 renal artery (group LDN-1), 8 cases with two renal arteries (group LDN-2), and 5 cases with 3 or more renal arteries (group LDN-3). The demographic data among the groups were similar. The mean operative time was significantly longer among groups LDN-2 (100.3 ± 9.5 minutes) and LDN-3 (120.6 ± 10.3 minutes) compared with LDN-1 (76.1 ± 9.3 minutes; P < .001). Similar results were observed with respect to warm ischemia times. There were no significant differences related to graft function and outcomes among these groups. CONCLUSION The single stapler and hand removal technique was safe, technically feasible, and cost effective regardless of the number of renal arteries and veins. This technique removes the necessity of additional staplers and extraction bags, lowers the operative and warm ischemia times, and thus decreases the cost.

Delayed presentation of a traumatic diaphragmatic rupture with intrapericardial herniation.

Thoracic and abdominal blunt traumas are the major causes of diaphragmatic rupture. These ruptures may be recognized at the time of the initial trauma, but are diagnosed months or even years later during the workup for related symptoms. We present herein a patient who suffered from abdominal pain and dyspnea years after a motor vehicle accident. A chest computed tomography (CT) demonstrated diaphragmatic rupture with intrapericardial herniation of intraabdominal organs. Exploratory laparotomy confirmed the diagnosis. In this report, we describe our management of this unusual diaphragmatic rupture.