Yasuhiro Munakata

Effects of peritoneal insufflation on hepatic and renal blood flow

The effects of peritoneal insufflation with carbon dioxide on hepatic and renal blood flow have not been reported hitherto. We evaluated these effects in a porcine model of abdominal laparoscopic surgery. Seven anesthetized pigs underwent peritoneal insufflation in a step-wise manner to create intraabdominal pressures of 6, 12, 18 and 24 mmHg, and changes in the arterial and venous pressure, arterial blood gases, and hepatic and renal blood flow were monitored. Both the hepatic and renal blood flow decreased as the intraabdominal pressure increased. Therefore, in order to carry out laparoscopic abdominal surgery safely in patients with hepatic or renal impairment, low intraabdominal pressures or noninsufflating techniques are recommended.

Preoperative diagnosis of strangulated Obturator hernia using ultrasonography

BACKGROUND Obturator hernia is rarely recognized before surgical intervention, since it is relatively infrequent and its definitive diagnosis is difficult. To change this situation, we introduced ultrasound examination in 1993 for differential diagnosis of strangulated obturator hernia among patients with bowel obstruction of unknown cause. PATIENTS AND METHODS Between 1993 and 1995, we encountered 15 patients with suspected obturator hernia based on the presence of bowel obstruction of unknown cause and so-called predisposing factors. These patients underwent ultrasound examinations. RESULTS The 4 patients with bowel obstruction caused by strangulated obturator hernia were all correctly diagnosed preoperatively by ultrasonography and were successfully cured by surgery. The time required for diagnosis was shorter than reported previously (average 16.5 h). CONCLUSIONS Ultrasonography is useful and reliable for the diagnosis of strangulated obturator hernia and can decrease the morbidity and mortality associated with delayed diagnosis.

A Novel Combined Laparoscopic-Endoscopic Cooperative Approach for Duodenal Lesions

PURPOSE A surgical approach with minimal invasion and excellent outcome for removal of duodenal lesions, using laparoscopic-endoscopic cooperative surgery (LECS), was established. PATIENTS AND METHODS Two patients underwent the resection of duodenal lesions with our novel LECS approach. Case 1 (age: 49 years; male) had a 20-mm 0-IIa-like lesion (group IV tumor on biopsy) in the duodenal bulb. LECS interventions, performed under general anesthesia, employed a total of four trocars. The extent of lesions was determined with the endoscopic submucosal dissection (ESD) technique. The affected duodenal wall was then perforated before a one fifth turn resection was performed to expose lesions of the whole layer. A tumor, confirmed under laparoscopy, was turned over toward the abdominal cavity to facilitate resection. Case 2 (age: 49 years; female) had 20-mm 0-IIc lesions (group III adenoma) located at the second portion of the duodenum. LECS procedures for duodenal resection were performed in a manner similar to case 1 . A total of five trocars were used. RESULTS Histologic diagnosis of the tumor in case 1 was tubular adenoma with moderate atypia (size: 20 x 12 mm). As for case 2, histopathologic findings confirmed a tubular adenoma with moderate atypia (size: 18 x 18 mm) and an adenoma-negative surgical margin. The postoperative courses, in both cases, were uneventful. CONCLUSIONS Although only 2 cases were surgically intervened with limited experience, the present novel LECS approach allowed a reliable, adequate resection of tumors located in the duodenum, with abbreviated operation times (156-179 versus 202-229 minutes), minimal bleeding, less postoperative stress imposed on the surgeons, and an uneventful postoperative course, compared to conventional surgical methods.

Laparoscopy Assisted Transduodenal Resection of a Periampullary Tumorat the Inferior Duodenal Angulus

Background: Duodenal adenoma is a rare lesion that requires resection because of its malignant potential. Minimally invasive surgery is desirable for such lesions. Case summary: A 52-year-old man underwent esophagogastroduodenoscopy, which revealed a 30-mm 0-IIalike lesion at the inferior duodenal angulus. Examination of the biopsy specimen revealed a Group IV adenoma. The tumor was treated by laparoscopic transduodenal ampullectomy, which was performed under general anesthesia and via 5 trocars. After laparoscopic mobilization of the duodenum and pancreas head, the duodenum was externalized through a mini-laparotomy. A longitudinal incision was placed in the duodenum, and the tumor was excised extracorporeally under direct vision; submucosal dissection was achieved with an electrocautery device. The mucosal defect and duodenal wall were closed with interrupted sutures. The tumor measured 26 mm × 25 mm and was diagnosed histologically as a tubular adenoma with low grade atypia. The surgical margin was adenomanegative. The postoperative course was uneventful. Conclusion: From our experience in this case, we deem laparoscopy-assisted transduodenal ampullectomy to be a feasible and safe procedure for a periampullary duodenal tumor.

Commentary on Laparoscopic-Endoscopic Cooperative Surgery for Duodenal Lesions

Laparoscopic wedge resection of gastric submucosal tumors is an established method, but the tumor is usually resected to an excessive extent [1,2]. Hiki et al. first reported laparoscopic-endoscopic cooperative surgery (LECS) for gastric tumors [3]. Under the LECS approach, the tumor can be resected with minimal but adequate surgical margin. We reported LECS for duodenal lesions in 2010 [4], but other such reports limited. Although LECS enables resection of the tumor with minimal but adequate surgical margin and without postoperative deformity or stenosis, the procedure is still not fully established.

A CASE OF SQUAMOUS CELL CARCINOMA OF THE PAPILLA VATER

十二指腸乳頭部原発の扁平上皮癌の1例を経験したのでその概要を報告する.症例は62歳,男性で上腹部痛,タール便を主訴として当院を受診した.上部消化管内視鏡検査で十二指腸乳頭部に白色,平皿状の腫瘍を認め,生検の結果は扁平上皮癌であった.膵頭十二指腸切除術を施行した.病理検査では腺癌成分のない純粋な扁平上皮癌と診断された.術後1年8カ月経過し,再発徴候を認めていない.十二指腸乳頭部原発の扁平上皮癌は稀な疾患で現在まで自験例を含め, 7例が報告されている. 4例に膵頭十二指腸切除術が施行され, 3例に1年以上の無再発生存が得られている.