妇科腹腔镜手术并发症的相关因素分析

目的 探讨妇科腹腔镜手术并发症及其相关因素.方法 回顾性分析江西省妇幼保健院2003年8月至2008年8月的8700例腹腔镜手术病例出现并发症的临床资料.结果 259例发生并发症,发生率为2.98%(259/8700),其中严重并发症37例(0.43%),需开腹处理者21例(0.24%);与穿刺及气腹有关的并发症129例,包括皮下气肿、腹壁淤血;出血性并发症20例;损伤性并发症17例;感染性并发症26例.结论 腹腔镜手术并发症与手术难度有关,应引起高度重视.正确掌握手术指征,提高手术技巧是预防腹腔镜手术并发症的关键.     

Rare entity: Ectopic liver tissue in the wall of the gallbladder - A case report

Ectopic liver tissue (ELT) is a rare condition, which is usually not diagnosed preoperatively, but coincidentally during abdominal surgery. While the location of ELT can vary, it is usually localized on the gallbladder wall or in close proximity. ELT is associated with various complications, a major complication being extrahepatic hepatocellular carcinoma. A 59-year-old female underwent elective surgery for chronic cholecystitis with stones. During laparoscopic exploration, a 2-cm-diameter ELT was detected in the anterior gallbladder wall and a laparoscopic cholecystectomy was performed. The case is presented due to the rare nature of ELT and as a reminder of ELT-related complications.     

电视腹腔镜甲状腺疾病手术并发症的防治(附100例病例报道)

目的探讨电视腹腔镜对甲状腺疾病手术治疗并发症的防治。方法该院于2002年3月￣2005年5月完成的电视腹腔镜下甲状腺疾病手术100例,观察其术后并发症及恢复情况。结果所有病例均在腹腔镜下完成手术,无中转开放手术。皮下气肿1例、皮下积液1例、甲亢术后复发1例,均经保守治愈;一过性声音嘶哑3例,经理疗等治疗治愈。术后全部病例顺利恢复,无重大并发症发生。结论电视腹腔镜甲状腺疾病手术治疗安全可靠,并发症少,术后恢复快。     

Laparoscopic diagnosis of retrograde peristalsis and intussusception in Roux‐en‐Y limb after laparoscopic gastrectomy: A case report

The cause of jejunojejunal intussusception, a rare complication after Roux‐en‐Y gastric surgery, remains unclear. Here, we present a case of retrograde jejunojejunal intussusception that occurred after laparoscopic distal gastrectomy with Roux‐en‐Y reconstruction. A 51‐year‐old woman who had undergone laparoscopic distal gastrectomy and Roux‐en‐Y reconstruction for early gastric cancer 6 years previously was admitted to our hospital with abdominal pain. Abdominal CT revealed the “target sign,” and she was diagnosed as having small bowel intussusception. Laparoscopic surgery resulted in a diagnosis of retrograde intussusception of the distal jejunum of the Roux‐en‐Y anastomosis with retrograde peristalsis in the same area. The Roux‐en‐Y anastomosis site and intussuscepted segment were resected laparoscopically. To the best of our knowledge, this is the first report of laparoscopic diagnosis of retrograde peristalsis in the distal jejunum of a Roux‐en‐Y anastomosis. Additionally, relevant published reports concerning this unusual condition are discussed.     

Laparoscopic surgery for repeated cecal volvulus with intestinal malrotation: A case report

This is the first report of laparoscopic surgery for an advanced‐age patient with cecal volvulus accompanied by intestinal malrotation. A 96‐year‐old woman who had previously undergone laparotomy for cecal volvulus underwent emergency laparoscopic surgery for recurrent volvulus. Because the cecum was about to rupture but not ischemic, we untwist the intestinal volvulus and fixed the cecum to the abdominal wall with a single suture. Five days after the surgery, the volvulus between the suture and the hepatic flexure of the colon recurred. We performed a second laparoscopic surgery in which we fixed the right side of the colon to the abdominal wall after diagnosing intestinal malrotation. Given its positioning, the sign of malrotation would not have been visible on preoperative CT images. As shown by this case, intestinal malrotation might lie behind the repeated cecal volvulus, and laparoscopic surgery may be a good option for volvulus with intestinal malrotation, even in cases with obstruction.     

Early gastric cancer successfully treated by endoscopic submucosal resection 1 year after laparoscopic sleeve gastrectomy with duodenal‐jejunal bypass

This case involved a 64‐year‐old female patient with a BMI of 35.3 kg/m² and poorly controlled type 2 diabetes mellitus. Preoperative upper gastrointestinal endoscopy revealed chronic, atrophic gastritis. Helicobacter pylori antibody was negative. The patient underwent laparoscopic sleeve gastrectomy with duodenal‐jejunal bypass as a metabolic surgery to treat obesity and type 2 diabetes mellitus. At 1 year postoperatively, routine endoscopy detected a flat elevated lesion at the distal gastric sleeve, near the posterior wall of the antrum; biopsy revealed adenocarcinoma. Endoscopic submucosal resection was performed without complication. This case shows the advantage of laparoscopic sleeve gastrectomy with duodenal‐jejunal bypass in screening the excluded stomach as compared to laparoscopic Roux‐en‐Y gastric bypass. Therefore, laparoscopic sleeve gastrectomy with duodenal‐jejunal bypass can be a viable alternative to laparoscopic Roux‐en‐Y gastric bypass for regions where gastric cancer is endemic.     

悬吊式与气腹腹腔镜在子宫肌瘤中的应用比较

目的比较腹壁皮下悬吊式腹腔镜与气腹腹腔镜手术治疗子宫肌瘤的临床价值。方法选取2013年5月-2014年4月该院收治的子宫肌瘤患者106例,依据随机数表法分为两组,分别采用1.5孔法腹壁皮下悬吊式腹腔镜子宫肌瘤切除术(观察组)和气腹腹腔镜子宫肌瘤切除术(对照组)。比较两组术中术后情况及并发症发生率。结果观察组平均手术时间为(62.04±18.69)min,切除肌瘤(5.83±1.29)个;对照组平均手术时间为(104.36±20.14)min,切除肌瘤(2.45±1.38)个。观察组患者的术中出血量、肛门排气时间、术后腹腔引流量及住院时间均明显低于对照组(P0.05)。观察组出现咳嗽3例(5.66%),尿潴留2例(3.77%),总发生率为9.43%;对照组出现咳嗽8例(15.09%),伤口感染1例(1.89%),尿潴留3例(5.66%),皮下气肿5例(9.43%),总发生率为32.07%。结论悬吊式腹腔镜子宫肌瘤切除术术后并发症发生率明显低于气腹腹腔镜手术,具有操作简单、安全性高的特点。     

Massive subcutaneous emphysema and hypercarbia: complications of carbon dioxide absorption during extraperitoneal and intraperitoneal laparoscopic surgery--case studies

The laparoscopic approach to surgery is being used with greater frequency as our healthcare system continues to strive for shorter hospital stays and improved postoperative patient recovery times. However, laparoscopy is not without potential complications. This article presents 2 patient case studies. The cases differ in surgical technique. One patient's laparoscopic surgery involved an extraperitoneal approach. The second patient's surgery involved an intraperitoneal approach. Massive subcutaneous emphysema developed in both patients. The phenomenon of subcutaneous emphysema associated with laparoscopic surgery will be defined and discussed.     

Laparoscopic intraperitoneal mesh repair of Spigelian hernia: A case report

Spigelian hernia is a rare congenital defect of the anterior abdominal wall located along the semilunar line through the aponeurosis fascia of the transversus abdominis muscle. It represents 1%–2% of all abdominal wall hernias. Few cases of laparoscopic treatment for Spigelian hernia have been reported, especially in Japan. However, several reports of laparoscopic surgery to repair Spigelian hernias have been published, and some have shown that the laparoscopic approach repair is feasible because it is associated with less morbidity and a shorter hospital stay than open surgery. We herein describe a 63‐year‐old Japanese woman who presented with painful bulging in the right lower abdominal quadrant. A preoperative diagnosis of Spigelian hernia was made, and we performed laparoscopic intraperitoneal repair. The patient was discharged 6 days after laparoscopic surgery with no perioperative complications. This report describes the first successful laparoscopic intraperitoneal mesh repair of Spigelian hernia in Japan.     

Laparoscopic obesity surgery in an Asian Institute: A 10‐year prospective study with review of literature

Objective: Obesity surgery is the most effective treatment for morbid obesity and leads to dramatic improvement in related co‐morbidities. The aim of this study was to present the long‐term results of a prospective trial studying the efficacy of laparoscopic obesity surgery in a group of oriental patients. Method: From April 1998 to March 2009, 2385 patients who underwent obesity surgery in a single bariatric center in Asia were recruited. Various procedures have been adopted so far, including laparoscopic vertical banded gastric partition in 652 patients (27.3%), laparoscopic gastric bypass (LGB) in 1228 patients (51.5%), laparoscopic adjustable gastric banding in 226 patients (9.5%), laparoscopic sleeve gastrectomy in 128 patients (5.4%), gastric balloon in 68 patients (2.8%) and laparoscopic revision surgery in 83 patients (3.5%). We evaluated the clinical data and effect of obesity surgery on different procedures. Results: Overall, the major complication rate and mortality were 1.5% and 0.12%. There was an increase of surgical risk in laparoscopic sleeve gastrectomy and laparoscopic revision surgery patients. The mean total weight loss for the population was 28.1%, 33.9%, 21.3% 18.7% and 17.4% at 1, 3, 5, 7 and 9 years after surgery, respectively. LGB had a better weight loss (30.1%) than that of the restrictive‐type procedures (20.9%) at 5 years after surgery. After surgery, most of the obesity‐associated co‐morbidities were resolved or improved in these patients. Conclusion: Laparoscopic obesity surgery resulted in significant and sustained weight loss in morbidly obese Asian patients with resolution of associated co‐morbidities. LGB had a better result in weight reduction than other restrictive procedures.     

Imaging of complications associated with port access of abdominal laparoscopic surgery

Advanced techniques and equipment in laparoscopic surgery offer advantages over open surgery, expanding the application of this minimally invasive procedure to a wide range of abdominal operations that used to be performed as an open procedure. Laparoscopic surgery is performed in the closed abdominal cavity in which the space is limited. To create a working space in the abdominal cavity, an artificial pneumoperitoneum is established and multiple ports are placed for the introduction of various laparoscopic instruments. Unlike open surgery in which the incision is made just above the target organ, laparoscopic access is made away from the area of dissection, with the instruments triangulated around the target organ within the abdomen. This fundamental difference in approach between the open and laparoscopic procedures may lead to peculiar postoperative complications after laparoscopic surgery, which may be present away from the target organ or in the abdominal wall, and be easily missed on postoperative imaging studies. These complications include port-related direct organ injuries, such as abdominal organ or vascular injury; abdominal wall complications related to laparoscopic port insertion such as vascular injury, infection, and hernia; abdominal wall complications related to specimen removal, such as port site tumor seeding and endometriosis; and complications related to gas insufflation. The radiologist plays an important role in the diagnosis of complications after laparoscopic surgery, and therefore should be familiar with the features of such complications on imaging scans in the era of laparoscopic surgeries.     

Case report of perineal hernia after laparoscopic abdominoperineal resection

Perineal hernia (PH) is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present a case report of perineal hernia after laparoscopic APR and discuss its management. The patient was a 77‐year‐old man who was diagnosed with lower rectal cancer. He underwent laparoscopic APR and bilateral lateral lymph node dissection. Two months after the surgery, pain and bulging in the perineal region developed, and PH was diagnosed by CT. Repair with a polypropylene mesh was performed using a combination of laparoscopic abdominal and transperineal approaches. Reportedly, the incidence of secondary PH after APR has increased along with the rate of laparoscopic surgery. Treatment of secondary PH with transperineal repair alone may cause injuries to other organs because of adhesion of the pelvic viscera. In the present case, we safely repaired the hernia repair using a laparoscopy‐assisted perineal approach.     

Parasitic leiomyoma in the trocar site after laparoscopic myomectomy: A case report

BACKGROUNDLaparoscopic myomectomy is increasingly used for resecting gynecological tumors. Leiomyomas require morcellation for retrieval from the peritoneal cavity. However, morcellated fragments may implant on the peritoneal cavity during retrieval. These fragments may receive a new blood supply from an adjacent structure and develop into parasitic leiomyomas. Parasitic leiomyomas can occur spontaneously or iatrogenically; however, trocar-site implantation is an iatrogenic complication of laparoscopic uterine surgery. We describe a parasitic leiomyoma in the trocar-site after laparoscopic myomectomy with power morcellation.CASE SUMMARYA 50-year-old woman presented with a palpable abdominal mass without significant medical history. The patient had no related symptoms, such as abdominal pain. Computed tomography findings revealed a well-defined contrast-enhancing mass measuring 2.2 cm, and located on the trocar site of the left abdominal wall. She had undergone laparoscopic removal of uterine fibroids with power morcellation six years ago. The differential diagnosis included endometriosis and neurogenic tumors, such as neurofibroma. The radiologic diagnosis was a desmoid tumor, and surgical excision of the mass on the abdominal wall was successfully performed. The patient recovered from the surgery without complications. Histopathological examination revealed that the specimen resected from the trocar site was a uterine leiomyoma.CONCLUSIONClinicians should consider the risks and benefits of laparoscopic vs laparotomic myomectomy for gynecological tumors. Considerable caution must be exercised for morcellation to avoid excessive tissue fragmentation.     

Subcutaneous carbon dioxide emphysema following laparoscopic salpingo-oophorectomy: a case report

Multiple patient and economic benefits have contributed to the widespread popularity of laparoscopic surgery. Although the laparoscopic approach is safe, it is not without potential complications. The following case study describes a patient undergoing a laparoscopic salpingo-oophorectomy who had a sudden rise in end-tidal carbon dioxide to 65 mm Hg and was found to have developed subcutaneous emphysema. Hyperventilation, close monitoring, and mechanical ventilation for 4 hours postoperatively resulted in a positive patient outcome. The mechanisms of carbon dioxide absorption, as well as risk factors, complications, treatment, and prevention of subcutaneous emphysema will be described.     

Non–exposed endoscopic wall‐inversion surgery for pediatric gastrointestinal stromal tumor: A case report

Gastrointestinal stromal tumors (GIST) in patients under 18 years of age are classified as pediatric GIST. Pediatric GIST are extremely rare, and there are no reports of laparoscopic‐endoscopic cooperative surgery for these lesions. We report the use of non‐exposed endoscopic wall‐inversion surgery as a laparoscopic‐endoscopic cooperative surgery‐related procedure for the treatment of a pediatric GIST. The case involved a 17‐year‐old male patient who presented with anemia and was found to have a bleeding gastric tumor. The tumor was resected transorally using the non‐exposed endoscopic wall‐inversion surgery technique. No gene mutation of c‐Kit or Platelet‐Derived Growth Factor Receptor α (PDGFRα) was found, and the final pathological diagnosis was epithelial‐type GIST due to a succinate dehydrogenase abnormality. Follow‐up included a CT scan every 4 months. No recurrence has occurred to date.     

Blood flow evaluation using PINPOINT® in a case of incarcerated inguinal hernia: A case report

Indocyanine green (ICG) fluorescence for intestinal blood flow has been reported, but application during laparoscopic surgery for incarcerated inguinal hernia has not been reported. Here, we report the case of a patient with an incarcerated inguinal hernia in whom the bowel was preserved after evaluation of intestinal blood flow with ICG fluorescence using PINPOINT®, a brightfield full‐color, near‐infrared fluorescence camera. A man in his 80s was diagnosed with incarcerated inguinal hernia and underwent laparoscopic surgery. The ascending colon and mesentery showed deep red discoloration on gross evaluation. However, intravenous injection of ICG revealed uniform fluorescence of the mesentery and bowel wall, indicating the absence of irreversible ischemic changes of the bowel. As such, no resection was performed, and transabdominal preperitoneal patch plasty was completed. The patient had a good postoperative course. In this case, ICG fluorescence with the PINPOINT was useful to avoid bowel resection during laparoscopic surgery.     

Single‐incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum

We report a case involving a minimally invasive single‐incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59‐year‐old man presented with a 35‐mm lesion located in the second portion of the duodenum. A local resection was performed via single‐incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single‐incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.     

Ovarian vein thrombosis following total laparoscopic hysterectomy

Ovarian vein thrombosis usually occurs in pregnant patients, especially during the postpartum period. However, it is a rare complication following laparoscopic surgery in gynecology. The risk of a thromboembolic event is not well defined, and evidence‐based guidelines regarding deep vein thrombosis prophylaxis in gynecological laparoscopic surgery are still lacking. Herein we report a rare case of ovarian vein thrombosis following total laparoscopic hysterectomy in a 35‐year‐old woman who developed a fever of unknown origin on postoperative day 3. A complete fever work‐up was done. Her urine, vaginal stump and blood culture were all negative, and her white blood cell count was normal. CT revealed left ovarian vein thrombosis. The patient responded well to anticoagulation in conjunction with antibiotic therapy.     

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: A case report and literature review

The occurrence of intra‐abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74‐year‐old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine‐needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory‐white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.     

A newly designed magnet‐retracting forceps for laparoscopic cholecystectomy in a swine model

We designed a method for remote‐controlled endoscopic surgery using magnet‐retracting forceps. To evaluate the feasibility of this technique, laparoscopic cholecystectomy was attempted in a swine model. This method takes advantage of the attractive force between two magnets, one inserted into the peritoneal cavity and the other located outside the abdominal wall. An intra‐peritoneal magnet was fixed to the fundus of the gallbladder using an endovascular clip. Laparoscopic cholecystectomy was accomplished by magnetic retraction of the gallbladder. This magnet‐retracting forceps provided port‐less access to the abdominal cavity. Since the direction and range of retraction were unrestricted by the location of access‐ports fixed on the abdominal wall, surgery could be less invasive. In addition, this procedure provided surgeons with excellent endoscopic views, as retraction force was supplied without any shaft device in the abdomen. This operation system using magnetic retraction appears promising.