腹腔镜辅助Meckel憩室切除术

目的:探讨Meckel憩室的腹腔镜诊断及治疗方法。方法:总结分析2002年6月至2008年6月我们用腹腔镜诊断治疗Meckel憩室35例患者的临床资料。35例均于腹腔镜下找到憩室后结扎切除或延长脐部切口腹腔外切除吻合。结果:Meckel憩室并下消化道出血25例(71.4%),反复脐周或右下腹痛6例(17.1%),肠梗阻4例(11.5%)均治愈出院。术中腹腔镜探查确诊16例,占45.7%。手术时间45～90min,平均70min,平均住院时间5.6d。结论:腹腔镜辅助Meckel憩室切除术患者创伤小、疼痛轻、康复快,是诊断治疗Meckel憩室的良好方法。     

Laparoscopic management of Meckel's diverticulum in children

Background

Rectal bleeding, recurrent abdominal pain, nausea, and vomiting in children could present a diagnostic as well as therapeutic challenge. Meckel's diverticulum (MD) is one of the causes. The objective of the current study was to evaluate the feasibility and outcome of laparoscopic management of MD.

Methods

The clinical data of 33 children admitted with rectal bleeding and/or recurrent abdominal pain with no identifiable cause were reviewed over a period of 8 years. There were 23 boys and 10 girls with a mean age of 5.12 ± 2 years (range, 3-12 years). In 21 cases, MD was an incidental finding on laparoscopic appendectomy and symptomatic in 12 cases. Patients with rectal bleeding were subjected to upper gastrointestinal endoscopy; colonoscopy, and technetium Tc 99m-labeled pertechnetate scan (MS). All patients were subjected to routine laboratory investigations and diagnostic laparoscopy.

Results

Of the 1200 appendectomies, incidental MD was found in 21 (1.9%) patients and symptomatic in 12 cases. Upper gastrointestinal endoscopy and colonoscopy did not show a bleeding source in 7 patients presented with bleeding per rectum. Four cases showed a positive MS uptake. Of these, 3 were found on laparoscopy to have an MD. Three cases showed a negative scan. Of these, 2 had an MD. In 5 cases with recurrent abdominal pain nausea, vomiting, and abdominal distention, diagnostic laparoscopy revealed Meckel's diverticulitis in 3 cases and intussusception secondary to MD in 1 case. Laparoscopic Meckel's diverticulectomy and laparoscopic-assisted Meckel's diverticulectomy was done for 18 and 12 cases, respectively. Ectopic gastric mucosa was present in 13 cases (44%).

Conclusions

Laparoscopy is safe, cost-effective, and efficient for the diagnosis and definitive treatment of MD. Compared with conventional laparotomy, it has the advantage of precise operative diagnosis, less traumatic access, fewer intraoperative and postoperative complications, and shorter recovery period.     

Intussusception associated with a Meckel's diverticulum and a duplication cyst

Intussusception is a frequent cause for bowel obstructions and pediatric surgical consults. First described by Barbette in 1674, the etiology and treatment of intussusception has undergone several revisions for the last 300 years. Currently, we understand most intussusceptions in young children to be of idiopathic in nature with the incidence of pathologic lead points increasing with the age of the child. Although both Meckel's diverticulum and duplication cysts have both been reported numerous times in the past as a source of a lead point, we report, to our knowledge, the only case of both found in a child requiring operative reduction.     

Incarcerated amyand hernia

Amyand’s hernia is a rare condition defined by the inclusion of the appendix vermiformis within the hernia sac. Its incidence among cases of groin hernia is less than 1%. The clinical manifestation of incarcerated inguinal hernia generally masks the symptoms and signs of acute appendicitis, which renders preoperative diagnosis difficult. In this study, we present two cases of Amyand’s hernia that were diagnosed preoperatively. The patients were taken for operation with the prediagnosis of ?ncarcerated inguinal hernia. We evaluated these cases along with data from prior studies.     

Incarcerated spontaneous transdiaphragmatic intercostal hernia

Introduction

Prolapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency.

Presentation of case

A 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect.

Discussion

The clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient''s history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient.

Conclusion

Spontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.     

Laparoscopic treatment of Meckel's diverticulum

We present two cases in which complication of a Meckel's diverticulum were dealt with, and in one case diagnosed using the laparoscope. One was a large bleeding diverticulum containing ectopic gastric mucosa, with the diagnosis suggested preoperatively, confirmed laparoscopically, and the pathology resected extracorporeally. The second was a partial intermittent small-bowel obstruction due to torsion around the mesodiverticular band, diagnosed and resected via the laparoscope. The literature of Meckel's diverticula and complications is reviewed, with open and laparoscopic treatment options. Although uncommon, many cases of Meckel's diverticulum may be quite suitable for laparoscopic diagnosis and treatment.     

Laparoscopy in the diagnosis of bleeding Meckel's diverticulum

A rare case of bleeding Meckel's diverticulum in an adult, in which Tc-99m pertechnetate scan, mesenteric angiography, and barium examination failed to establish the diagnosis, is presented. The diagnosis was made by laparoscopy, and a laparoscopically assisted resection was carried out with a smooth postoperative course, early discharge from the hospital, and rapid return to work.     

Operative treatment of ventral hernia using prosthetic materials

Objective The objective of this study was to summarize the clinical experiences in repairing abdominal incisional hernia with prosthetic materials. Methods Eighty-three patients with ventral hernia were analyzed retrospectively. Results Two patients developed pulmonary infection, one developed adhesive ileus, and five developed wound infection. All wounds healed completely during follow-up. Seventy-three (88%) patients were free of pain, and ten patients (12%) felt pain in the operated area within the last month; only one patient required pain-relieving drugs. Twenty-nine patients (35%) felt discomfort, such as stiffness. Four cases experienced postoperative recurrence. Conclusions Incisional herniorrhaphy with prosthetic materials is safe and effective but has a high discomfort rate. Open giant incisional hernia or recurrent incisional hernia should be performed by trained surgeons. Placing mesh in a suitable position and using a patch with minimal reaction and enough tensile strength may improve the prognosis. Further studies are necessary utilizing light polypropylene mesh.     

Giant Meckel’s diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum(MD) results from incomplete involution of the proximal portion of the vitelline(also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anom-aly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagno-sis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD(≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was suc-cessfully managed by surgical resection and anasto-mosis created with endoscopic stapler device(80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopatho-logic examination indicated Meckel's diverticulitis with-out gastric or pancreatic metaplasia.     

Pancreas transplant and incidental Meckel's diverticulum: not always a straightforward decision

Abstract: Introduction: Unexpected intraoperative findings are not rare in surgical practice. Meckel’s diverticulum with a mass is one such example. There are only two previously reported cases of Meckel’s in transplantation, and neither involved pancreas transplant. Results and discussion: We present a case report of novel surgical technique using a Meckel’s diverticulectomy site for the duodeno‐enterostomy to managing the exocrine secretions of the transplanted pancreas. We also discuss management of Meckel’s diverticulum. The patient tolerated the procedure without complication, and continues to have normal renal and pancreatic function without any gastrointestinal (GI) complaints. The excised Meckel’s diverticulum contained both gastric and pancreatic tissue. Conclusion: Although uncertainty about the best management practices exists in the general surgery patient population, given the potential complications that may arise from Meckel’s diverticulum, in transplant patients the Meckel’s should be removed when encountered. The point of excision can safely be incorporated into other intestinal anastomoses.     

Laparoscopic ventral hernia repair using a two (5-mm) port technique.

OBJECTIVE: High recurrence rates have been documented after primary repair of incisional hernias. Laparoscopic ventral and incisional hernia repairs have been performed with very low rates of recurrence. We have modified the standard technique of laparoscopic repair in patients with small incisional and ventral hernias. The purpose of this study was to document the technique utilizing only two 5-mm ports and demonstrate that it is safe, effective, and feasible. METHODS: Three patients with small incisional or ventral hernias were examined. The standard laparoscopic ventral hernia repair technique was modified as follows: two 5-mm ports were inserted on opposite sides of the defect. The defects ranged from 2.5 cm to 4 cm in size. Expanded polytetrafluoroethylene mesh (DualMesh, WL Gore, Flagstaff, AZ) was used to cover the hernia defect, overlapping the defect margins circumferentially by 3 cm. The mesh diameter ranged from 8.5 cm to 10 cm. The mesh was inserted through a 5-mm skin incision site and affixed into position with transfascial sutures and spiral tacks. RESULTS: The operative time ranged from 53 minutes to 57 minutes. All patients were discharged home the day of surgery and reported minimal postoperative pain. Follow-up ranged from 6 months to 1 year; all patients were doing well without recurrence. CONCLUSION: Laparoscopic repair of ventral or incisional hernias can be performed using only two 5-mm ports. This technique can be done on an outpatient basis in a safe, timely fashion.     

腹腔镜诊治儿童美克尔憩室出血

目的研究腹腔镜在儿童Meckel憩室出血诊断和治疗中的应用。方法分析近年来采用腹腔镜治疗的Meckel憩室出血病例31例,男19例,女12例。结果腹腔镜治疗31例Meckel憩室中1例因粘连广泛改行开腹手术,合并肠重复畸形1例,肠套叠2例。其中楔形切除吻合12例,肠切除端-端吻合18例。同时进行了3例阑尾及4例斜疝的联合手术。结论腹腔镜的应用为儿童Meckel憩室出血的诊断和治疗提供了一条极好的途径,具有诊断和治疗的双重作用。提高了疾病的诊断率,减少了并发症的发生率,降低了医疗费用。     

Occult ventral hernia defects: a common finding during laparoscopic ventral hernia repair

BACKGROUND: In many incidences, laparoscopic exploration reveals occult ventral hernia defects that were not detected on physical examination. The objective of this study was to describe the frequency of occult ventral hernia defects detected during laparoscopy. METHODS: Prospectively collected data on 146 consecutive patients who underwent laparoscopic ventral hernia repair were reviewed. The numbers of ventral defects found on preoperative physical examination were compared with those found during the laparoscopic procedure. RESULTS: Out of 146 laparoscopic ventral hernia repair patients, 70 patients (48%) were found to have occult defects that were not detected on preoperative abdominal examination. Among all the possible variables, only the type of hernia was found to have a significant difference. CONCLUSION: Almost half of the patients with a ventral hernia have clinically occult hernia defects that can be recognized laparoscopically. This indicates the importance of careful inspection of the anterior abdominal wall during the surgical procedure.     

Evaluation of new prosthetic meshes for ventral hernia repair

Background In hernia repair, particularly laparoscopic hernia repair, direct contact between mesh and abdominal organs cannot always be avoided. Several mesh materials and composite meshes have been developed to decrease subsequent adhesion formation. Recently, new meshes have been introduced. In an experimental rat study, their value was established and compared with that of meshes already available on the market. Methods In 200 rats, eight different meshes were placed intraperitoneally and in direct contact with abdominal viscera. The following meshes were tested: polypropylene (Prolene), e-PTFE (Dualmesh), polypropylene– polyglecaprone composite (Ultrapro), titanium–polypropylene composite (Timesh), polypropylene with carboxymethylcellulose–sodium hyaluronate coating (Sepramesh), polyester with collagen-polyethylene glycol–glycerol coating (Parietex Composite), polypropylene–polydioxanone composite with oxidized cellulose coating (Proceed), and bovine pericardium (Tutomesh). At 7 and then at 30 days postoperatively, adhesion formation, mesh incorporation, tensile strength, shrinkage, and infection were scored by two independent observers. Results Parietex Composite, Sepramesh, and Tutomesh resulted in decreased surface coverage with adhesions, whereas Prolene, Dualmesh, Ultrapro, Timesh, and Proceed resulted in increased adhesion coverage. Parietex Composite, Prolene, Ultrapro, and Sepramesh resulted in the most mesh incorporation. Dualmesh and Tutomesh resulted in significantly increased shrinkage. There were no differences in mesh infection. Parietex Composite and Dualmesh resulted in a moderate inflammatory reaction, as compared with the mild reaction the other meshes exhibited. Conclusion Parietex Composite and Sepramesh combine minimal adhesion formation with maximum mesh incorporation and tensile strength. The authors recommend the use of these meshes for hernia repair in which direct contact with the abdominal viscera cannot be avoided.     

A strangulated Spigelian hernia mimicking diverticulitis

Summary Spigelian hernias are true interparietal hernias that are frequently not associated with a palpable mass and, as such, are not frequently diagnosed before surgery. Reported herein, is the serendipitous discovery of an incarcerated Spigelian hernia that was discovered on a CT scan being performed for presumed diverticulitis.     

National trends in the surgical management of Meckel's diverticulum

Background

Treatment recommendations for Meckel's diverticulum (MD) come mostly from single-institution case series. The objective of this study was to review the surgical management and outcomes of children undergoing Meckel's diverticulectomy using contemporary data from a national database.

Methods

We queried 2007 to 2008 data from the Pediatric Health Information System database and analyzed demographic and outcome variables for patients undergoing surgical resection of MD. Cases were classified as primary (symptomatic MD) or secondary (incidental MD). Outcomes in primary cases were compared between open and laparoscopic approaches. Statistical analyses were performed using SPSS (Chicago, IL).

Results

Eight hundred fifteen children underwent Meckel's diverticulectomy. Meckel's diverticulectomy was more common in boys (boy-girl, 2.3:1), and half (53%) of the children required surgery before their fourth birthday. More cases (n = 485; 60%) were classified as primary, and most children were approached by laparotomy (75%). The most common presentations for primary cases were obstruction (30%), bleeding (27%), and intussusception (19%). In the primary group, patients treated with the laparoscopic approach had a shorter length of stay (open approach, 5.7 ± 5.2 days; laparoscopic approach, 4.3 ± 2.7 days; P < .02).

Conclusion

These data describe current trends in the surgical treatment of MD in the United States. Laparoscopic Meckel's diverticulectomy appears to shorten length of stay but is used much less frequently than the traditional open approach.     

Coexistence of abdominal cocoon,intestinal perforation andincarcerated Meckel’s diverticulum in an inguinal hernia: Atroublesome condition

Sclerosing encapsulating peritonitis(SEP) is a rare dis-ease entity, in which the small intestine becomes en-cased and mechanically obstructed by a dense, fibrotic membrane. The disorder is characterized as either primary(idiopathic) or secondary to other causes. The idiopathic cases of SEP, which lack any identifiable eti-ology according to clinical, radiological and histopatho-logical findings, are also reported under the designation of abdominal cocoon syndrome. The most frequent presenting symptoms of all SEP cases are nausea, vom-iting, abdominal distention and inability to defecate, all of which are associated with the underlying intestinal obstruction. Persistent untreated SEP may advance to intestinal perforation, representing a life-threatening condition. However, preoperative diagnosis remains a particular clinical challenge, and most diagnoses are confirmed only when the typical fibrous membrane en-casing the small intestine is discovered by laparotomy. Here, we report the clinical presentation of an 87-year-old male with signs of intestinal obstruction and the ul-timate diagnosis of concurrent abdominal cocoon, rightincarcerated Meckel's diverticulum, and gastrointestinal perforation in laparotomy.