腹腔镜胆囊切除术后切口肿瘤种植的临床分析

目的:探讨腹腔镜胆囊切除术(LC)后切口肿瘤种植的诊断治疗及预防措施。方法:回顾分析1994年1月至2003年12月诊治LC术后切12肿瘤种植病例的临床资料。结果:LC 10 865例术后发生切口肿瘤种植4例(0.037％),表现为剑突下戳孔处质硬肿块,病理证实为转移性腺癌,但无法找到原发病灶。行肿块扩大切除后辅以局部放疗及全身化疗,分别随访40、20、10、1个月,1例在发现切口种植后3月因肿瘤远处转移死亡,1例在发现剑突下肿块后4月脐孔戳口处又见转移性腺癌,手术探查可见腹膜肿瘤种植,另2例未见肿瘤复发及转移。结论:LC术后切口肿瘤种植发生率低,但预后差,传统胆囊病理检查可漏诊原发癌灶。认识其临床表现与发病机制,有利于更好地指导临床工作。     

Splenosis mimicking local recurrence after laparoscopic radical nephrectomy

We report a case of retroperitoneal splenosis, which presented as a local recurrence after laparoscopic radical nephrectomy. Seeding of splenic tissue can occur after trauma and/or removal of the spleen and must be kept in mind when performing laparoscopic surgery.     

The vermiform appendix presenting in a laparoscopic port site hernia

Laparoscopic port site hernias (PSHs) are uncommon but present a potential source of morbidity due to incarceration of the hernial contents which is usually omental fat or small bowel. We report only the third case of the vermiform appendix presenting in a symptomatic PSH; we discuss the appropriate management of this condition as well as ways in which the incidence of PSHs may be reduced.     

Regional lymph node metastasis from port site implants after laparoscopic surgery

Although overall incidence of laparoscopic port site implants is decreasing, it remains problematic in patients with occult intraabdominal malignancy. Port-site metastases may themselves become the source of new metastases. A 42-year-old man underwent a laparoscopic cholecystectomy for cholelithiasis. One month later, he was diagnosed with a right colon cancer, for which a right colectomy was performed. Eleven months later, a CT scan showed nodules in the umbilicus (one of the original laparoscopic port sites) and behind the right rectus abdominis muscle, adjacent to the deep epigastric vessels. These sites were resected, and histopathology confirmed metastatic adenocarcinoma. The right deep epigastric nodule was reported to be lymph node–positive for metastatic adenocarcinoma. It is probable that dissemination of cancer cells to this lymph node occurred from the port site implants. Presence of metastasis in the lymph nodes draining the abdominal wall should be examined in all patients with port site implants.     

杂交式经脐单孔腹腔镜脾切除术6例报告

目的:探讨杂交式经脐单孔腹腔镜脾切除术的可行性、安全性、实用性及优缺点。方法:2011年11月至2012年12月为6例患者(免疫性血小板减少性紫癜4例、遗传性球形红细胞增多症2例)施行杂交式经脐单孔腹腔镜脾切除术。4例应用自制单孔腹腔镜入路装置,2例应用SILS入路装置。6例均采用左腋前线肋缘下2 cm处辅助5 mm切口,通过此孔留置引流管。结果:6例杂交式经脐单孔腹腔镜脾切除术均获成功,手术时间150～225 min,平均(189.2±31.8)min;术中出血量50～200 ml,平均(108.3±58.5)ml;术后住院6～9 d,平均(7.2±1.2)d。术后随访3～14个月,患者恢复良好,脐部切口位置隐蔽,美容效果佳。结论:杂交式经脐单孔腹腔镜脾切除术安全、可行,具有更佳的美容效果。但此手术难度较高,应严格把握适应证。     

经X-CONE单孔与传统腹腔镜脾切除术的对比研究

目的 比较经 X-CONE 单孔腹腔镜和传统多孔腹腔镜行脾切除的安全性及可行性.方法 分析 2012 年 4 月至 2013 年 9 月经 X-CONE 单孔腹腔镜脾切除 12 例（ A 组）,应用传统多孔腹腔镜脾切除 19 例（ B 组）.比较两组病例的手术时间、标本取出时间、术中出血量、术后镇痛指数 （ VAPS ）、术后肛门排气时间、术后引流时间、术后住院时间、术后并发症、住院费用、美容效果评分等,并对结果进行分析.结果 两组患者均成功完成手术,A 组无中转为传统腹腔镜和开腹手术病例,两组均无明显手术并发症.两组病例比较在术中出血量、术后镇痛指数（ VAPS ）、术后肛门排气时间、术后引流时间、术后住院时间、住院费用等方面无统计学差异.A 组病例手术时间（ 168.4 ± 67.7 ） min 明显长于 B 组手术时间（ 105.4 ± 21.7 ） min,差异有统计学意义（ t = 2.57,P ＜ 0.05 ）.而两组病例标本取出时间,A组（ 4.1 ± 1.1 ） min少于 B 组（ 9.9 ± 3.0 ） min,差异有统计学意义（ t = -4.91,P ＜ 0.01 ）.术后美容效果评分 A 组（ 7.9 ± 1.1 ）分优于 B 组（ 6.4 ± 1.0 ）分,差异有统计学意义（ t = 3.89,P ＜ 0.01 ）.结论经 X-CONE 单孔腹腔镜行脾切除的安全性和可行性与传统多孔腹腔镜相当,美容效果突出,为患者提供了另一个微创技术的选择.     

Splenoportal thrombosis as a complication after laparoscopic splenectomy

Laparoscopic splenectomy is performed with increasing acceptance for hematologic disorders, with low complication rates reported. Splenoportal thrombosis following splenectomy is a rare complication, anecdotally reported after laparoscopic procedures. We here describe a case of thrombosis of the spleno-mesenteric-portal axis 14 days after a laparoscopic splenectomy using Ligasure. Abdominal ultrasound scans and Doppler examination allowed us to diagnose this event, and an angio-MR scan performed afterward confirmed the diagnosis. Heparin therapy was promptly begun. The patient was then switched to oral anticoagulant therapy, with resolution of the clinical features. The patient was discharged after 1 week of anticoagulant therapy with a stable Doppler ultrasound pattern. Early diagnosis and prompt initiation of anticoagulant therapy associated with careful surgical technique may reduce the risk of this life-threatening complication.     

Preventing port site inversion in laparoscopic adjustable gastric banding

OBJECTIVES: Laparoscopic adjustable gastric banding (LAGB) is a safe, controlled method for weight loss in the morbidly obese patient. Inversion or dislodgement of the port leads to difficulty with access for band adjustments and frequently requires reoperation. We report our experience with port fixation to the rectus sheath of the abdominal wall by using port/mesh fixation to prevent port site complications. METHODS: One hundred and ninety-one morbidly obese patients underwent LAGB between April 2002 and August 2005. The first group had ports fixed to the rectus fascia of the abdominal wall with a standard 4-point suture technique. The second group had ports sutured to a mesh, which was then tacked to the rectus sheath of the abdominal wall. Port site complications were analyzed over a 5-month to 40-month period and compared between the 2 groups. Intraoperative port fixation times were recorded for each technique. RESULTS: Thirty-nine patients in the suture fixation group encountered a 20.5% port site complication rate, with 10.3% of the ports becoming dislodged or inverted. The mesh/tack group consisted of 151 patients. The port site complication rate was 5.3%, with only a 1.3% rate of port dislodgement or inversion. The port dislodgement or inversion rates were significantly different between groups (P = .0049). The average operative times for port insertion were 12 minutes for the sutured technique and 5 minutes for the mesh/tack technique. CONCLUSIONS: The mesh/tack method of port fixation reduced the incidence of dislodgement and rotation in our patient population, which resulted in greater ease of access for adjustments. Furthermore, the mesh/tack technique is a quick, safe approach for port fixation through a small incision.     

Splenic retrieval after laparoscopic splenectomy: a new bag

BACKGROUND: Laparoscopic splenectomy has become the gold-standard surgical approach for patients undergoing elective splenectomy. Little data exist concerning the technical difficulties of splenic retrieval. When the spleen is large, popular commercial retrieval bags are often too small to facilitate removal. The aim of this study was to compare our clinical experience utilizing two different retrieval bags, the Endocatch II (Autosuture, London, UK) and the developing E200 (Espiner Ltd., Bristol, UK). MATERIALS AND METHODS: We performed a retrospective review of all laparoscopic splenectomies performed at Hull Royal Infirmary, Kingston upon Hull, from March 1997 to July 2003. Patient demographics, morbidity, mortality, and clinical outcome had been entered prospectively into a database. Two patient groups were examined, depending on the type of retrieval bag utilized. Complications and instrument failure during splenic retrieval were analysed. RESULTS: A total of 83 laparoscopic splenectomies were performed. No retrieval bag was used in 8 cases (10%). The Endocatch retrieval bag was used for 45 (60%) patients and the E200 for 30 (40%) patients. The mean operative time for the former group was 65 minutes (range, 50-127 minutes) and for the latter, 120 minutes (range, 80-180 minutes) (P < 0.05). Bag-related complications were 2 (4%) perforations and 2 (4%) failures to deploy while using the Endocatch bag. CONCLUSION: The Endocatch bag is easy to deploy but is associated with perforation and cannot be used for large spleens. The E200 bag is more useful for large spleens but is associated with prolonged operative time due to poor maneuverability. Improved technology is still required.     

An unusual case of port site metastasis after laparoscopic cholecystectomy in a renal transplant patient: a case report

Port site metastasis after laparoscopy is a rarely seen intraabdominal malignancy independent of tumor stage. We present an unusual case of port site adenocarcinoma metastasis from unknown origin following laparoscopic cholecystectomy. A 52-year-old woman with a previous renal transplant underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. Six months later, she was admitted to the hospital with a complaint of a mass at the four trocar sites. A biopsy from the port sites led to the diagnosis of adenocarcinoma metastasis. Port site metastasis after laparoscopic cholecystectomy is seen especially after gallbladder cancer, and less frequently after intraabdominal malignancy independent of tumor stage. Our patient illustrated that port site metastasis probably spread from an undetected cancer site of an early stage intraabdominal tumor. Immunosuppression may have increased the likelihood of tumor seeding at the port sites.     

Gallbladder carcinoma late metastases and incisional hernia at umbilical port site after laparoscopic cholecystectomy

A potentially serious complication of laparoscopic cholecystectomy is the inadvertent dissemination of unsuspected gallbladder carcinoma. There are increasing reports of seeding of tumor at the trocar sites following laparoscopic cholecystectomy in patients with unexpected or inapparent gallbladder carcinoma. Although the mechanism of the abdominal wall recurrence is still unclear, laparoscopic handling of the tumor, perforation of the gallbladder, and extraction of the specimen without an endobag may be risk factors for the spreading of malignant cells. The Authors report the case of late development of umbilical metastasis after laparoscopic cholecystectomy; the presence of an incisional hernia and the finding of a stone in subcutaneous tissue demonstrate the diffusion of tumor cells into subcutaneous tissue during the extraction of gallbladder. The patient underwent an excision of the metastases. She is disease free two years after surgical treatment.     

Pathologically confirmed port site metastasis after laparoscopic radical prostatectomy: case report and literature review

Laparoscopic port site metastases remain exceedingly rare for urologic tumors, despite the increasingly widespread use of laparoscopic techniques in the management of urologic malignancy. We report a case of port site metastases after transperitoneal laparoscopic radical prostatectomy.     

Prevention and management of complications in urological laparoscopic port site placement

OBJECTIVES: To review complications associated with urological laparoscopic port-site placement and outline techniques for their prevention and management. METHODS: Review of the literature using Medline. RESULTS: Laparoscopy now plays a key role in urological surgery. Its applications are expanding with experience and evolving data confirming equivalent long-term outcome. Although significant port-site complications are uncommon, their occurrence impacts significantly on perioperative morbidity and rate of recovery. The incidence of such complications is inversely related to surgeon experience. Ports now utilise bladeless tips to reduce the incidence of vascular and visceral injuries, and subsequently port-site herniation. Metastases occurring at the port site are preventable by adhering to certain measures. CONCLUSIONS: Whether performing standard or robot-assisted laparoscopy, port-site creation and maintenance is critical in ensuring minimal invasiveness in laparoscopic urological surgery. Although patient factors can be optimised perioperatively and port design continues to improve, it is clear that adequate training is central in the prevention, early recognition, and treatment of complications related to laparoscopic access.     

Hand-assisted laparoscopic splenectomy vs conventional laparoscopic splenectomy in cases of splenomegaly

HYPOTHESIS: Laparoscopic splenectomy (LS) is the procedure of choice for elective splenectomy. Splenomegaly may preclude safe mobilization and hilar control using conventional laparoscopic techniques. Hand-assisted LS (HALS) may offer the same benefits of minimally invasive surgery for splenomegaly while allowing safe manipulation and splenic dissection. DESIGN: A retrospective review of patients with splenomegaly undergoing conventional LS or HALS was performed. SETTING: Tertiary care referral center. PATIENTS: Hand-assisted LS was performed at the start of the operation for patients with splenomegaly; splenomegaly was determined by palpation of the splenic tip extending to the midline or the iliac crest, or by a craniocaudal splenic length of greater than 22 cm. Splenomegaly was defined as a splenic weight of greater than 700 g after morcellation. MAIN OUTCOME MEASURES: Patient demographic characteristics, operative indications, splenic weight after morcellation, morbidity, mortality, and clinical outcomes were evaluated. RESULTS: Forty-five patients with splenomegaly were identified: 31 underwent standard LS and 14 underwent HALS. The HALS group had significantly larger spleens than the conventional LS group (mean weight, 1516 vs 1031 g; P =.02). Mean operative time (177 vs 186 minutes; P =.89), estimated blood loss (602 vs 376 mL; P =.17), and length of hospital stay (5.4 vs 4.2 days; P =.24) and complication rates (5 [36%] of 14 vs 5 [16%] of 31; P =.70) were similar between the HALS and the standard LS groups. No perioperative mortality occurred. CONCLUSIONS: Hand-assisted LS is a safe and efficacious procedure for these extremely difficult cases. Hand-assisted LS provides the benefits of a minimally invasive approach in cases of splenomegaly.