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Monosegment 4±1 Associating Liver Partition and Portal Vein ligation for Staged hepatectomy (ALPPS) for bilateral colorectal liver metastases decreases the risk of drop-out of two stage hepatectomy, triggering a rapid and significant increase in future liver remnant (FLR) with promising oncological outcomes. We report two cases of segment 4+1 monosegment ALPPS for multiple colorectal liver metastases performed at our institution. In the literature, seven similar cases have been reported. Short and long term outcomes of our two patients were reported along with a review of data from the literature. Our patients showed a FLR increase from 13% to 37% and from 14% to 41% of total liver volume, respectively. This was compared to a median growth from 19% at baseline to 34% before stage 2, in the literature. After 20 and 27 months since resection both patients are alive and disease-free. In the literature, median overall survival and disease free survival were 13 months (range, 5-24 months) and 5 months (range, 3-23 months), respectively. Segment 4±1 ALPPS is associated with promising oncological outcomes and a significant FLR growth. It may be safely performed in selected patients as a salvage procedure, reducing the risk of the dropout of two-stage hepatectomy.

Right portal vein ligation (PVL) has its recognized role in inducing hypertrophy of future liver remnant (FLR) prior to major liver resection. The aim of this study was to evaluate the safety, feasibility, and effectiveness of laparoscopic right PVL and to explore its applications.Laparoscopic right PVL was employed either during staging laparoscopy when a right hepatic trisectionectomy was indicated, leaving a small (25%) FLR (indication 1), or during a laparoscopic left hepatic lobectomy (left lateral sectionectomy) when a second-stage right hemihepatectomy was to follow (indication 2). A follow up cross-sectional liver imaging was performed 4-6 weeks later with liver volumetry to confirm hypertrophy of the FLR before proceeding to major hepatectomy.Six patients (female, 5), 74-83 years old, underwent a laparoscopic right PVL, of whom 4 patients fulfilled indication 1 while 2 patients fulfilled indication 2. The median operating time for indication 1 was 60 minutes. There were no intra- or postoperative complications, and all procedures were completed laparoscopically. Repeat imaging of the liver demonstrated a median (range) hypertrophy of FLR of 24.5% (range, 20.7-33.1%). The right liver experienced atrophy.In the hands of the experienced laparoscopic hepatobiliary surgeon, laparoscopic right PVL is feasible and safe, and induces adequate regeneration of the FLR. Laparoscopic right PVL has its applications at the time of staging laparoscopy in patients requiring a right hepatic trisectionectomy in the presence of a small FLR and as part of a staged liver resection in patients with bilobar liver disease that spares segments 1 and 4.

The safety and efficacy of laparoscopic splenectomy in the management of benign hematologic diseases is well established. However, most consider the laparoscopic approach to splenectomy in trauma patients contraindicated. We present a 76-year-old Jehovah's Witness who sustained a blunt abdominal trauma, rib fractures, and grade III splenic injury. She continued to lose blood, albeit slowly, for which she underwent preemptive urgent laparoscopic splenectomy with the use of the red cell saver. The operating time was 65 minutes. She was discharged on the 16th postoperative day after recovering from fractured ribs with subsequent pulmonary atelectasis and basal pneumonia. Whereas the majority of grade I to III splenic injuries in adults can be managed conservatively, some 20% will fail and require emergency splenectomy for delayed rupture of the spleen. In a Jehovah's Witness patient, early splenectomy for injury with the use of red cell saver is advised. This may be accomplished laparoscopically in the hemodynamically noncompromised patient.

Advancements in surgical technique and technology have facilitated safe laparoscopic liver resection in selected patients. The aim of this study is to evaluate the feasibility and outcome of laparoscopic liver resection. Patients with lesions situated in the anterior and left lateral segments were selected for laparoscopic resection. Data were collected prospectively. Between 2003 and 2007, 24 patients (12 males) with a median (range) age of 65 (30–83) years underwent 24 laparoscopic hepatic resections for presumed colorectal metastases (n = 20) and other indications (n = 4). The resections included left hepatic lobectomy (n = 14), other resections of two or three segments with or without metastasectomy (n = 5), left hemihepatectomy (n = 2) and unisegmentectomy (n = 3). All procedures were completed laparoscopically. Median operating time was 155 min. Estimated median (range) blood loss was 100 (25–1100) ml and one patient received two units blood transfusion. The operative morbidity rate was 4%, and there were no operative deaths. The median (range) postoperative hospital stay was 3 (1–14) days. At median (range) follow-up of 13.5 (5–36) months, 4 patients (21%) had disease recurrence and 17 patients (89%) remained alive. In selected patients with lesions in the anterior and left lateral segments, laparoscopic liver resection is feasible, achieves adequate cancer resection and is associated with smooth and rapid recovery. Long-term follow-up data are required for oncological results.

INTRODUCTION Laparoscopic cholecystectomy remains the most frequently performed minimally invasive operation for general surgeons. The next step toward "scar-less" surgery uses a modified single multichannel port inserted through the umbilicus. METHODS The use of a single port requires modification of the currently established technique for laparoscopic cholecystectomy with a single-port protocol. This new method presents a few technical difficulties and challenges compared with the conventional 3-port or 4-port laparoscopic cholecystectomy. We discuss maneuvers to help overcome these difficulties based on our initial experiences. All the data for the procedures that were performed were prospectively collected and analyzed. RESULTS Single port cholecystectomy was attempted in 30 patients (all females) with no intraoperative/postoperative complications from September 2008 to March 2008. In all, 20 of 30 patients had their operation completed with the use of a single port. An extra 5-mm epigastric port was required in 8 of the 20 patients. Another 2 of 20 patients required conversion of the operation into a standard laparoscopic technique (1x3-port and 1x4-port procedure). All the patients were discharged within 24 hours. There were no intraoperative or postoperative complications or mortalities. CONCLUSIONS The single-port technique is feasible for performing routine laparoscopic procedures. With further advances in surgical technique, technology, and instrumentation, this technique can be reproduced to perform more complex biliary and other procedures in future.

A 46-year-old gentleman, being investigated for symptoms of generalised weakness, low-grade fever and weight loss, was found to have a large, infiltrative mass of the liver on CT scan. The radiological impression was that of advanced hepatic malignancy with involvement of lesser curve of the stomach and regional lymph nodes. Multiple biopsy attempts failed to yield an adequate tissue sample for histopathological diagnosis. Surgery was planned for left hemihepatectomy with resection of the hepatogastric ligament and partial gastrectomy. Frozen section of a peroperative tissue sample confirmed the diagnosis of hepatic tuberculosis (TB). The granulomatous area was debrided and anti-TB treatment was started postoperatively. Recovery was unremarkable and the patient is currently asymptomatic.

Morbidly obese patients are predisposed to developing abdominal wall hernias with the potential complication of small bowel obstruction. We report a patient who developed an obstructed paraumbilical hernia a few days after laparoscopic gastric bypass and died of aspiration pneumonia after re-laparoscopy. The controversy regarding the optimal time and method of repair of abdominal wall hernias in patients undergoing laparoscopic gastric bypass is discussed with emphasis placed on either a simultaneous repair or to split the omentum to one side leaving incarcerated omentum that is plugging the hernia defect in place for a delayed repair.

Bleeding from stomal varices is uncommon. Local measures to control the bleeding offer short-lived control. Our experience with transjugular intrahepatic porto-systemic shunt (TIPS) and variceal embolisation is presented and appraised.Three patients presented with bleeding from stomal varices (Child-Pugh class B, n=2 and class C, n=1) in association with primary sclerosing cholangitis, autoimmune hepatitis and alcoholic liver disease. Local treatment measures including suture ligation, sclerotherapy and re-siting of the stoma achieved short-lived control. TIPS were inserted in all 3 patients, with embolisation of the stomal varices in 2.The radiological interventions were uncomplicated and resulted in cessation of the bleeding in all patients. One of the patients has had no further bleeding at 12 months' follow-up post-TIPS insertion. The other two patients re-bled at 5 and 6 months post-TIPS insertion and were successfully managed by insertion of a second TIPS in one patient and by balloon dilatation of the TIPS in another. The former patient has had no re-bleeding at a further 8 months' follow-up, while the latter had re-bleeding at 12 months post-TIPS insertion and underwent liver transplantation.Transjugular intrahepatic porto-systemic shunt with variceal embolisation offers an effective, minimally invasive management option in patients with bleeding stomal varices, and may be used as the primary mode of intervention in conjunction with medical therapy, and as the definitive therapy in patients unfit for surgery. TIPS and variceal embolisation do not preclude subsequent liver transplantation, and may be used during the acute situation as a bridge to transplantation.

Background Surgical factors are an important cause of early renal allograft loss and contribute to patient morbidity and mortality. The United Kingdom National Confidential Enquiry into Peri-operative Deaths has reported that operating out of normal working hours was associated with higher patient mortality because of inexperienced surgeons. In this study, we looked into whether operating outside normal working hours or the grade of the surgeon affected the incidence of surgical complications. We also examined the relationship between cold ischemic time (CIT) and likelihood of surgical complications. Patients and methods We performed a retrospective review of 322 adult recipients who received their first cadaver kidney transplant in our center between January 1, 1998 and June 30, 2001. Information on surgical complications were collected from patients' records. CIT, time of surgery, and grade of the operating surgeons was obtained from a local audit database (www.nwkta.org.) and the database held by UK Transplant. Results Surgical complication(s) were less likely to occur if one of the surgeons was a consultant (P =0.002). We found no association between cold storage and incidence of surgical complication(s). The median CIT was 21.30 (range 3.3-43.5) hours, n=229, in the group without complications compared with 21.80 (8.8-47.9) hours, n=77, for those with complications. The incidence of surgical complications was the same regardless of whether the operation took place during the day, evening, or night. Conclusions Prolonged CIT and operating out of normal working hours did not increase the incidence of surgical complications. Presence of a consultant did, however, reduce the likelihood of a surgical complication occurring.