Search

One of the complications of pancreatitis is pancreatic pseudocyst. Many different techniques have been described for internal drainage of pancreatic pseudocyst. Indication for surgery is either symptomatic or large cysts that can turn into complications such as hemorrhage, obstruction, infection, rupture and malignancy. Our technique includes an incision between 5 cm to 9 cm below the left subcostal margin and the opening of the anterior stomach and a posterior cystgastrostomy performed with a reticulated laparoscopic staple. We have been able to perform surgery in a very large pseudocyst (up to 26 cm) in a small amount of time, within 45 min, and with a shorter length of hospital stay (36 h). In this paper, we present our technique on how to approach large pseudocysts utilizing a minimally invasive small incision.

Background: This is a case of a solitary hepatic gastrinoma in a 65-year-old male. The patient was diagnosed with Zollinger-Ellison syndrome in 1991. He had negative radiologic and surgical explorations at that time. He was maintained on proton-pump inhibitors for the next 10 years without symptoms., Methods: A computed tomographic (CT) scan done in April 2001 demonstrated a 5-cm right hepatic lesion. Radionucleotide scanning with octreotide demonstrated intense activity in the same area in the right hepatic lobe. His serum gastrin was 317 pg/mL. He underwent laparoscopic radiofrequency ablation of the lesion., Results: Treatment resulted in a 6-cm ablative area giving a 1-cm margin on the tumor. One- and 3-month follow-up CT scans demonstrated adequate ablation of the tumor. An octreotide scan done 3 months postoperatively did not reveal any areas of abnormal uptake., Conclusion: We report success with laparoscopic radiofrequency ablation as an alternative to major hepatic resection in patients with a solitary hepatic gastrinoma.

Background: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gastroesophageal reflux disease (GERD)., Methods: Morbidly obese patients (n = 435) who underwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery., Results: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p<0.001); water brash (from 18% to 7%, p<0.05); wheezing (from 40% to 5%, p<0.001) laryngitis (from 17% to 7%, p<0.05); and aspiration (from 14% to 2%, p<0.01) following LRYGBP. Postoperatively, the use of medication decreased significantly both for proton pump inhibitors (from 44% to 9%, p<0.001) and for the H2 blockers (from 60% to 10%, p<0.01). SF-36 physical function scores and the mental component summary scores improved after the operation (87 vs 71; p<0.05 and 83 vs 66; p<0.05, respectively). Overall patient satisfaction was 97%., Conclusion: LRYGBP results in very good control of GERD in morbidly obese patients with follow-up as late as 3 years. Morbidly obese patients who require surgery for GERD may be better served by LRYGBP than fundoplication because of the additional benefit of significant weight loss.

This is, to our knowledge, the first case description of an extraadrenal pheochromocytoma located in the periadrenal fat. Pheochromocytoma is a tumor that originates in the chromaffin tissue. Extraadrenal pheochromocytomas have been described commonly in locations such as the organ of Zuckerkandle (29%); the bladder (12%); the sacrum, testis, rectum, and pelvic floor (2%); the upper abdomen in association with celiac, superior mesenteric, and inferior mesenteric ganglia (43%); the thorax (12%); and the neck (2%), most commonly in association with the ninth or tenth cranial nerve ganglion. Our patient was a 40-year-old woman known to have had an adrenal mass for the last 4 years. She was referred for surgery because of an increase in the size of the mass to 11 cm. Laparoscopic adrenalectomy was performed via a posterior flank approach. The pathology report was of periadrenal fat pheochromocytoma, with positive staining for synaptophysin, chromogranin, and vimentin. The patient was discharged on postoperative day 3. The unique feature in this case was the uncommon location of the extraadrenal tumor: the supraadrenal fat. The other unique finding in this case was that the pheochromocytoma was neither symptomatic nor malignant, common features of extraadrenal masses.

Due to major technical barriers, the safety and efficacy of laparoscopic hepatic resection is not well established. Laparoscopic liver resection has been described. Wedge resections or marginal resections rather than more formal hepatic resections for benign diseases only have been described lately. Anatomic hepatic resection and nonanatomical resection were also reported. But the technique still needs to be standardized and applied in a large-scale population. During the last 20 years, there has been a trend toward direct control of hepatic injury by adequate debridment of nonviable hepatic tissue along nonanatomical lines. The trauma experience emphasized two important concepts: the search for the most expedient method of hemorrhage control in the nonstable trauma patient, and a hepatic resection that need not be based on precise anatomic planes. The aim of this paper is to present the data and instruments available to apply toward laparoscopic liver resection.

Objective: The extraperitoneal laparoscopic approach (EXTRA) has been shown to be an effective and safe repair for primary (PIH), recurrent (RIH) and bilateral hernia (BIH). There is very little data examining the merits of laparoscopic repair for hernias under local anesthesia. In this' paper, we compare EXTRA performed under both general and local anesthesia., Methods: This nonrandomized prospective study was performed selectively on a male population only. Patients with associated pulmonary disease and high risk for general surgery were selected. Patients with recurrence and previous abdominal operations were excluded to decrease confounding variables in the study. A Prolene mesh was used in all patients., Results: Between May 1997 and September 1998, 92 male patients underwent the repair of 107 groin hernias using the EXTRA technique. The procedure was explained to them, and different anesthesia options were given. Fourteen of these repairs were performed under local anesthesia and 93 under general anesthesia. Of the 10 patients who underwent a repair under local anesthesia, there were 8 indirect, 5 direct and 1 pantaloon. The mean age was 53 years. In the group of general anesthesia, the types of hernias repaired were 45 indirect, 30 direct and 11 pantaloon. The mean age was 45 years. The mean follow-up was 15 months. Each patient was sent home the same day. Two peritoneal tears were recorded in the first group. The operative time was longer in the local group (47 +/- 11 vs 18 +/- 3). None of the patients required conversion to an open technique or change of anesthesia. No recurrences were found in either group. The average time of return to work and regular activity was 3.5 +/- 1 and 3 +/- 1 days, respectively., Conclusion: There appears to be no significant difference in recurrence and complication rates when the EXTRA is performed under local anesthesia as compared to general. Blunt dissection of the preperitoneal space does not trigger pain and does not require lidocaine injection. The most painful area is the peritoneal reflection over the cord structure. The laparoscopic repair under local anesthesia represents an advantage in the repair of the inguinal hernia, particularly in the population where general anesthesia is contraindicated.

Background: In 1975, researchers introduced the use of a large unsutured polyester mesh prosthesis placed in the preperitoneal space for inguinal hernia repair. Different stapling devices have been used to secure this mesh, and the most common complication of the procedure is nerve damage secondary to the staples. The necessity of stapling has never been demonstrated. We designed a prospective randomized study of the need for stapling in laparoscopic extraperitoneal repair of inguinal hernias with 1-year and 3-year followup., Study Design: Inclusion criteria of the study were men older than 18 years and first-time inguinal hernia repair. Patients with recurrence and previous abdominal operations were excluded to avoid confounding variables. Each patient's hernia was assigned a consecutive random number chosen by computer, with each number corresponding to an assigned group. The first group had stapled mesh and the second had unstapled mesh., Results: Data were collected over a 15-month period, with each procedure having a mean followup time of 8 months. A total of 100 procedures was performed in 92 patients. The two groups of patients were well matched for age and the type of hernia repaired. There were no recurrences in either group and no complications or deaths., Conclusions: The initial 12-month followup showed no significant differences in recurrence or complication rates between the stapled and unstapled groups. Both groups returned to work within an average of 4 days. A net savings of $120 was realized for each hernia repair performed without stapled mesh. In addition, stapling presents an inherent risk of nerve damage.

Objective: The purpose of this report is to describe the authors' technique for the laparoscopic repair of paraesophageal hernias and the outcome in their series of patients., Methods: Thirty patients underwent elective laparoscopic repair of paraesophageal hernias. All were pure type II paraesophageal hernias as defined by upper gastrointestinal contrast studies. All operations were performed by a single surgeon (JKE) assisted by five different chief surgical residents. The authors have used various prototypes of a laparoscopic utility belt to reduce the physician requirement to the surgeon and a first assistant. The operative setup and specific techniques of the repair are described and illustrated. A concomitant anti-reflux procedure was performed in the last 23 patients., Results: Satisfactory repair using video-laparoscopic techniques was achieved in all cases. There were no deaths. Complications occurred in 8 of 30 patients. Postoperative gastroesophageal reflux developed in three of the first seven patients in whom fundoplication was not performed. Three consecutive patients had left lower lobe atelectasis believed to be related to endotracheal tube displacement during the passage of the bougie. One patient had postoperative dysphagia. There was one case of major deep venous thrombosis with pulmonary embolism. Twenty-eight of 30 patients were discharged home by postoperative day 3. Twenty-four of 30 patients had returned to normal activity by the time of their first postoperative office visit 1 week after surgery.