Pandora's box and retrorectal tumors in laparoscopy: A case report and review of the literature

INTRODUCTION

Retrorectal tumors are uncommon and the etiology diverse. Literature to define the preoperative diagnosis and plan the intraoperative management are uncommon.

PRESENTATION OF CASE

We describe a case of a 44 year old patient with a laparoscopic approach for the removal of a retrorectal tumor and emphasize on the preoperative diagnostics and the intraoperative, minimal invasive approach.

DISCUSSION

Especially because these tumors are rare and often an incidental finding in gynecologic surgery, it is important to know the various differential diagnoses and its consequences with the laparoscopic approach.

CONCLUSION

We suggest the laparoscopic approach in cases of retroperitoneal cysts of unknown origin is ideal also because anatomic structures, mostly nerves, can be easily spared.     

Laparoscopic Duodenojejunostomy for Treatment of Superior Mesenteric Artery Syndrome

Background and Objectives:

Superior mesenteric artery (SMA) syndrome is a rare disorder, recognized as weight loss, nausea, vomiting, and post-prandial pain due to compression and partial obstruction of the third portion of the duodenum by the SMA. If conservative treatment fails, then laparotomy with duodenojejunostomy or lysis of the ligament of Treitz is indicated. Recently, laparoscopic division of the retroperitoneal attachments of the duodenum has been described. We report the first case of laparoscopic duodenojejunostomy as the definitive treatment of vascular compression of the duodenum.

Methods:

A very thin woman with a diagnosis of SMA syndrome was prepared for surgery after having failed medical therapy. The patient was placed in a supine position, and four laparoscopic ports were required to perform a 5 cm duodenojejunostomy.

Results:

The patient did well postoperatively. A gastrograffin study revealed no leak with patency of the duodenojejunal anastomosis. She was subsequently discharged home on a regular diet on postoperative day four.

Conclusion:

Laparoscopic duodenojejunostomy is a viable option to treat vascular compression of the duodenum. It provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient.     

Laparoscopically Assisted Spinal Surgery

Background:

Spinal surgery is one of the newest frontiers of videolaparoscopic surgery, but requires the cooperative efforts of both the spinal surgeon and the laparoscopic general surgeon.

Data Base:

We report our experience with 76 cases of laparoscopic spinal surgery, using both a transperitoneal and a retroperitoneal approach. Technical details and complications are described in detail.

Conclusions:

Fifty-one patients had a transperitoneal approach with an average operating time of 117 minutes. Uncomplicated cases stayed 4.4 days. Five patients required conversion. All but one patient had L5-S1 level surgery. Twenty-five patients had a retroperitoneal approach with 150 minutes operating time and a 5.7 day stay. Conversions were minimized with a two-balloon technique. The retroperitoneal approach allows for multiple level surgery with virtually unlimited fusion devices. Laparoscopically assisted spine surgery affords all the benefits of minimally invasive surgery, without limitations for the spinal surgeon.     

Laparoscopic Excision of Local Recurrence of Renal Cell Carcinoma

Background and Objective:

To report a single center''s experience with laparoscopic excision of local recurrence of renal cell carcinoma.

Methods:

Between January and August 2011, 5 patients who underwent laparoscopic excision of local recurrence were identified from the institutional laparoscopic surgery database.

Results:

Four radical nephrectomies and 1 partial nephrectomy were performed for primary tumors. The mean ages of the patients were 57.4 y (range, 48 to 68) and 62.8 y (range, 53 to 71) at the time of primary surgery and laparoscopic recurrence excision, respectively. The average size of the primary tumor was 7.2cm (range, 4.5 to 11). The mean size of local recurrence was 3.46cm (range, 2.8 to 4.5). The original tumor T stages were T1b, T2b, and T4 in 3, 1, and 1 cases, respectively. The mean time to diagnosis of recurrence was 51.2 mo (range, 15 to 136). The pathology of one patient who had previously received targeted therapy with sunitinib, was necrosis, unlike the other 4 pathologies which revealed renal cell carcinoma. The mean operative time, estimated blood loss, and length of hospital stay were 86 min (range, 70 to 100), 100 mL (range, 20 to 300), and 4 d (range, 2 to 8), respectively. One pleural injury did not need open conversion and was repaired laparoscopically. At a mean follow-up of 8.4 mo, the cancer-specific and disease-free survival rates were 100% and 60%, respectively.

Conclusion:

Laparoscopic excision of local recurrence of RCC is a feasible technique in well-selected patients with low-volume mass not involving the adjacent organs.     

Experimental laparoscopic aortobifemoral bypass for occlusive aortoiliac disease

Objective

To describe a totally laparoscopic technique for aortobifemoral bypass to treat aortoiliac atheromatous occlusive disease.

Design

A feasibility study.

Setting

A university teaching hospital.

Subjects

Six piglets weighing between 70 and 80 kg were submitted to a totally laparoscopic retroperitoneal aortobifemoral bypass, performed through six trocar sites, with abdominal suspension and a gasless technique. No minilaparotomy was performed. After systemic heparinization, the infrarenal aorta was cross-clamped and the aortic bifurcation stapled. An end-to-end aorto–prosthetic anastomosis was performed. Retroperitoneal tunnels were created to allow each limb of the graft to join its corresponding femoral artery by a conventional anastomosis.

Intervention

Totally laparoscopic aortobifemoral bypass.

Main Outcome Measures

Duration of the procedure, intraoperative blood loss and operative complications, bleeding in the immediate postoperative period. Evaluation of the aortic anastomosis at autopsy.

Results

All aortobifemoral bypasses were completed in less than 4 hours. Intraoperative blood loss did not exceed 250 mL. No intraoperative complication was encountered except occasional bleeding at the aortic anastomosis upon releasing the arterial clamp. This was controlled with a collagen sponge (three cases) or extra stitches (two cases). The animals were observed for 15 minutes before sacrifice. Autopsy revealed a normal aortic anastomosis in all cases and a normal progression of the limbs of the graft under the ureters in the retroperitoneal tunnels.

Conclusions

This animal model demonstrates the feasibility of the aortobifemoral bypass through a laparoscopic approach. The retroperitoneal anatomy of the piglet is similar to that of man. Aortic surgery can be conducted as for the standard technique. We used a similar approach to perform the first human, totally laparoscopic aortobifemoral bypass with an end-to-end anastomosis.     

Comparison of extracapsular pseudotumors seen in magnetic resonance imaging and in revision surgery of 167 failed metal-on-metal hip replacements

Background and purpose

Magnetic resonance imaging (MRI) is important for detecting extracapsular pseudotumors, but there is little information on the accuracy of MRI and appropriate intervals for repeated imaging. We evaluated the sensitivity and specificity of MRI for detecting pseudotumors in 155 patients (167 hips) with metal-on-metal (MoM) hip arthroplasties that failed due to adverse reactions to metal debris (ARMD).

Methods

Preoperative MRIs were performed with two 1.5 T MRI scanners and graded by a senior musculoskeletal radiologist using a previously described MRI pseudotumor grading system. Revision findings were retrieved from surgical notes, and pseudotumors were retrospectively graded as fluid-filled, mixed-type, or solid.

Results

The sensitivity of MRI was 71% and the specificity was 87% for detecting extracapsular pseudotumors. The sensitivity was 88% (95% CI: 70–96) when MRI was performed less than 3 months before the revision surgery. Interestingly, when the time that elapsed between MRI and revision was more than 1 year, the sensitivity calculated was only 29% (95% CI: 14–56). Comparison between MRI and revision classifications gave moderate agreement (Cohen’s kappa = 0.4).

Interpretation

A recent MRI predicts the presence of a pseudotumor well, but there is more discrepancy when the MRI examination is over a year old, most likely due to the formation of new pseudotumors. 1 year could be a justifiable limit for considering a new MRI if development of ARMD is suspected. MRI images over a year old should not be used in decision making or in planning of revision surgery for MoM hips.Metal-on-metal (MoM) hip replacements have been widely used for the treatment of hip osteoarthritis, particularly in young and active patients (Bozic et al. 2009). During the last few years, an increased risk of developing soft tissue reactions linked to increased wear of MoM articulation has been reported (Pandit et al. 2008, Kwon et al. 2010, Langton et al. 2011). An umbrella term “adverse reaction to metal debris” (ARMD) has been used to describe these tissue reactions, which include metallosis, aseptic lymphocytic vasculitis-associated lesions, and the fluid-filled or solid extracapsular lesions often referred to as pseudotumors (Langton et al. 2011). Most patients have high blood metal ions and many experience pain in the groin and thigh region, but ARMD may also be found in patients presenting with no clinical symptoms and normal whole-blood metal ion levels (Hart et al. 2011, Wynn-Jones et al. 2011). Asymptomatic extracapsular pseudotumors have been reported to increase and decrease in size with occasional remission of small masses, and they may involve the abductor and iliopsoas muscles (Almousa et al. 2013). Revision surgeries because of pseudotumors have been reported to have significantly poorer outcome than hip revisions for other reasons (Grammatopolous et al. 2009). Imaging is therefore needed to identify these patients for closer follow-up or revision surgery. Preoperative magnetic resonance imaging (MRI) is also of importance for surgeons to visualize the location and dimensions of the pseudotumor for optimal resection (Liddle et al. 2013).MRI and ultrasonography are the main imaging modalities for assessment of ARMD lesions. Modern MRI techniques allow good visibility in the hip region, even though intracapsular lesions cannot be reliably assessed in some cases due to metal artifacts. To our knowledge, only 1 study has compared pseudotumors seen in MRI with those actually found in revision surgery (Liddle et al. 2013).The main aim of this study was to evaluate the ability of preoperative MRI to detect extracapsular pseudotumors encountered in revision surgery and to assess appropriate intervals for repeated imaging, when development/progression of soft tissue pathologies is suspected. A secondary aim was to ascertain whether pseudotumors fall into the same categories in both MRI and revision surgery classifications.     

Laparoscopic Management of Obstructing Small Bowel GIST Tumor

Background:

Gastrointestinal stromal (GIST) tumors make < 1% of all gastrointestinal neoplasms and 20% of small bowel neoplasms. The most common acute presenting symptom of these tumors is gastrointestinal hemorrhage with obstruction being rare. We discuss our laparoscopic approach to 2 patients with small bowel GIST tumors that presented to our institution with obstruction of the small bowel.

Case Presentation:

Two patients presented to the emergency department with signs and symptoms of small bowel obstruction. On workup, each was found to have a solid lesion either within or adjacent to the small bowel at the point of obstruction and both were emergently taken to the operating room. The pathologic diagnosis of small bowel GIST tumor was the same in both cases, but the pathophysiologies of the obstructing tumors were different.

Results:

Both patients underwent laparoscopic surgery with successful resection of the lesions. The details and crucial points of the laparoscopic approach to these tumors are described with specific attention to its appropriateness and safety in treating GIST tumors. Attention to particular details of the manipulation and management of the bowel in the face of obstruction and removal of the lesions is described.

Conclusion:

The laparoscopic approach to GIST tumors of the small bowel, even in the face of emergent surgery, is a safe method.     

Laparoscopic Mucin Removal in Patients with Pseudomyxoma Peritonei

Background and Objectives:

Pseudomyxoma peritonei results from ovarian and appendiceal mucinous tumors. Cyst rupture results in intraabdominal mucin accumulation, leading to abdominal distension. No effective treatment has yet been established. Pseudomyxoma peritonei is generally associated with a poor prognosis. In a recent Mayo Clinic report, the 5-year survival rate for this disease was 53% and the 10-year survival rate was 32%, while the Memorial Sloan-Kettering Cancer Center reported 5- and 10-year survival rates of 75% and 10%.

Methods and Results:

In this report, we describe 4 patients with a laparoscopically confirmed recurrence of pseudomyxoma peritonei who subsequently underwent repeated laparoscopic mucin removal.

Conclusion:

Because laparoscopic surgery can be performed frequently, it appears that laparoscopic surgery, a minimally invasive procedure, greatly improves the quality of life of patients with pseudomyxoma peritonei.     

Laparoscopic diagnosis and treatment of a hydrocele of the canal of Nuck extending in the retroperitoneal space: A case report

INTRODUCTION

Hydrocele of the canal of Nuck is a rarely encountered entity. We report a case underwent laparoscopic totally extraperitoneal (TEP) treatment for a hydrocele of the canal of Nuck extending in the extraperitoneal space mainly.

PRESENTATION OF CASE

A 37-year-old woman complained of painless and reducible swelling in her left groin, and referred to our hospital for surgical management against left inguinal hernia with the incarcerated ovary. Ultrasonography and MR images revealed a cystic mass in the retroperitoneal space, and we diagnosed as an unusual type of hydrocele of the canal of Nuck. The patient was scheduled for laparoscopic treatment. Laparoscopic findings on pneumoperitoneum showed an extraperitoneal cystic tumor with no contact with the left ovary. The fascia and peritoneum of the port site were closed, and then an extraperitoneal space was created. The cystic tumor with the round ligament of the uterus was dissected and resected by the TEP technique. The extended deep inguinal ring was repaired with polypropylene mesh. Postoperative course was uneventful.

DISCUSSION

Hydrocele of the canal of Nuck in the adult female is a rare condition. The accurate diagnosis of an inguinal hydrocele in a female is seldom made. Laparoscopic examination provides surgeons with information of inguinal swelling accompanied with retroperitoneal cyst, and consecutive treatment by laparoscopic technique, especially TEP, is useful in regard to minimal damage of the peritoneum.

CONCLUSION

Laparoscopic diagnosis and TEP treatment offers a useful alternative in selected patients with hydrocele of the canal of Nuck.     

Giant retroperitoneal leiomyosarcoma. Multiorgan block removal

INTRODUCTION

Retroperitoneal tumors are rare, mostly malignant. Locally aggressive, and more frequent in women in their 5th decade of life. Its symptoms are nonspecific, including abdominal pain and palpable mass. To diagnosis is helpful computed tomography and biopsy. It needs surgery for absolute healing.

PRESENTATION OF CASE

67 years old man was admitted with back pain and fever. Abdominal imaging tests showed a 15 cm abdominal mass without clear organodependencia. Endoscopy with biopsies evidenced mesenchymal neoplasia of undetermined origin. In surgery we confirm its resecability and was necessary multiorgan resection. Pathologic diagnosis: well differentiated retroperitoneal leiomyosarcoma. Started adjuvant radiotherapy. In subsequent tests showed the presence of liver metastases.

DISCUSSION

Retroperitoneal tumors are developed from nerve, vascular, muscular, connective, supportive and fibroareolar tissue from this space. Its size does not modificate survival or resectability. We used TC and biopsy for its diagnose. Adjuvant therapy does not affect survival or quality of life, surgery remains the only curative option. Locoregional recurrence is the most influential figure in the prognosis. A large percentage of patients required a second surgery (between 45 and 82%).

CONCLUSION

The only curative option of retroperitoneal sarcomas is surgery, which usually requires multiple organ resection. Chemotherapy and radiotherapy are mostly a surgical supplement. Chemotherapy has not shown significant increase in survival.     

Mid common bile duct inflammatory pseudotumor mimicking cholangiocarcinoma. A case report and literature review

INTRODUCTION

Biliary inflammatory pseudotumors (IPTs) represent an exceptional benign cause of obstructive jaundice. These lesions are often mistaken for cholangiocarcinomas and are treated with major resections, because their final diagnosis can be achieved only after formal pathological examination of the resected specimen. Consequently, biliary IPTs are usually managed with unnecessary major resections.

PRESENTATION OF CASE

A 71-year-old female patient underwent an extra-hepatic bile duct resection en-bloc with the gallbladder and regional lymph nodes for an obstructing intraluminal growing tumor of the mid common bile duct (CBD). Limited resection was decided intraoperatively because of negative for malignancy fast frozen sections analysis in addition to the benign macroscopic features of the lesion. Histologically the tumor proved an IPT, arising from the bile duct epithelium, composed of inflammatory cells and reactive mesenchymal tissues.

DISCUSSION

The present case underlines the value of intraoperative reassessment of patients undergoing surgical resection for histopathologically undiagnosed biliary occupying lesions, in order to optimize their surgical management.

CONCLUSION

The probability of benign lesions mimicking cholangiocarcinoma should always be considered to avoid unnecessary major surgical resections, especially in fragile and/or elderly patients.     

Management of the hemophilic pseudotumor of the abdomen: A rare pathological entity

INTRODUCTION

Hemophilic pseudotumor is a rare complication that occurs in patients with severe hemophilia. Results from multiple episodes of bleeding into the bones and soft tissues.

PRESENTATION OF CASE

A 31 years old male patient, with severe hemophilia A. Diagnosed with an abdominal tumor 10 years ago during routine screening, that progressively grew to encompass the entire abdominal area, with symptoms of intestinal obstruction.

DISCUSSION

Hemophilic pseudotumor appears as a painless tumor of slow growth that can compress vital organs producing bone destruction, muscle and skin necrosis. The tumor may have fistulas or break spontaneously.

CONCLUSION

The abdominal hemophilic pseudotumor is a rare pathological entity, with few reports worldwide, but must be considered in hemophilic patients with a well documented abdominal tumor.     

A case of clear cell adenocarcinoma arising from endometriosis of the rectum treated by laparoscopic surgery

INTRODUCTION

Malignant transformation of intestinal endometriosis occurring in the extraovarian sites is extremely rare. We report a very rare case of clear cell adenocarcinoma arising from endometriosis of the rectum.

PRESENTATION OF CASE

An 83-year-old woman was admitted with the complaint of hematochezia. Colonoscopy revealed a tumor around about half of the rectal circumference. Biopsy of the tumor revealed a well-differentiated adenocarcinoma. Low anterior resection was undergone laparoscopically under the diagnosis of rectal carcinoma. Histopathological examination revealed clear cell adenocarcinoma, invading the sub-serosa of the rectum, but no metastasis of the lymph nodes. Immunohistochemical staining showed strong positivity for cytokeratin 7, but no staining for cytokeratin 20 and CDX2. The tumor existed adjacent to the endometrial glands, which were stained positive for Estrogen receptor. Ultimately, the patient was diagnosed with clear cell adenocarcinoma arising from endometriosis. Eighteen months after surgery, there are no signs of tumor recurrence.

DISCUSSION

Clear cell adenocarcinoma arising from intestinal endometriosis has been reported in 7 cases, including our case. Careful observation is required because the prognosis of endometriosis after malignant transformation remains poor.

CONCLUSION

We report a very rare case of clear cell adenocarcinoma arising from endometriosis of the rectum treated by laparoscopic surgery.     

Laparoscopic Resection of Giant Adrenal Cavernous Hemangioma

Background:

Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy.

Methods:

Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass.

Results:

The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland.

Conclusion:

The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.     

Adrenalectomy by Retroperitoneal Laparoendoscopic Single Site Surgery

Background:

Laparoscopic adrenalectomy is the current standard for treatment of benign adrenal disease. To reduce the invasiveness of surgery, new techniques have been recently proposed, such as mini-laparoscopy, natural orifice transluminal endoscopic surgery, and laparoendoscopic single site surgery (LESS). Herein, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports.

Case Report:

A 52-year-old female patient with an incidental finding of a 3-cm mass in the left adrenal was referred to us. Preoperative blood concentrations of catecholamines, aldosterone, and cortisol, and urinary excretion of vanilmandelic acid were normal. She underwent an adrenalectomy by retroperitoneal LESS using conventional instruments and ports. Operative time and estimated blood loss were 82 minutes and <50cc, respectively. She was discharged 12 hours after surgery. No intra- or postoperative complications occurred. Pathological analysis of the specimen identified an adrenal cortical adenoma.

Conclusion:

Adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments is feasible. Further studies must be performed to evaluate safety, indications and benefits of this approach.     

Surgical strategy in abnormally increased Fluorine-18 fluorodeoxyglucose uptake in an asymptomatic lower esophageal submucosal tumor – Report of a case

INTRODUCTION

Leiomyoma is the most common benign tumor of the esophagus (67–80%), it represents 0.4–1% of all esophageal tumors.

PRESENTATION OF CASE

An incidentally discovered gastro-esophageal submucosal tumor was found to have increased fluorine-18-fluorodeoxyglucose (FDG) uptake on positron emission computed tomography (PET/CT). After laparoscopic surgical exploration and local enucleation the tumor turned out to be a benign esophageal leiomyoma.

DISCUSSION

There are few reports of esophageal leiomyomas with a positive uptake on (PET/CT) and even fewer adopting our combination of a minimally invasive approach and frozen section examination as a management plan. Our approach avoided excessive morbid surgical resections and underestimation of a malignant disease.

CONCLUSION

We report this case hoping to expand the existing literature on the topic and to highlight the limitations of PET/CT in guiding the diagnosis and subsequently the management of esophageal submucosal tumors.