Small bowel volvulus with no malrotation after laparoscopic appendicectomy: Case report and literature review

INTRODUCTION

Small bowel volvulus, as a complication of laparoscopic surgery, is a rarely reported clinical entity. We present a case of a young female who developed small intestinal volvulus after laparoscopic appendicectomy. She had this complication in the absence of malrotation or other previous abdominal operations.

PRESENTATION OF CASE

A 17-year-old woman presented with acute appendicitis. After an uneventful laparoscopic appendicectomy, she developed acute small intestinal obstruction on the second post-operative day. A prompt laparotomy showed small bowel volvulus, which was reduced, with no evidence of malrotation. She had an uneventful recovery and was discharged within 3 days of the second operation, in a stable condition.

DISCUSSION

This article presents a review of the literature of this rare cause of small intestinal obstruction after laparoscopic surgery, stressing on the importance of early diagnosis and treatment. A discussion of the potential factors predisposing to this entity is presented, emphasising the need of a higher-evidence study as to its aetiology and prevalence.

CONCLUSION

Small bowel volvulus is a rare complication of laparoscopic surgery, but its early diagnosis and prompt treatment is essential to avoid morbid outcomes. Surgery is the therapeutic mainstay.     

An unusual presentation of perforated appendicitis in epigastric region

INTRODUCTION

Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation.

PRESENTATION OF CASE

A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver.

DISCUSSION

While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality.

CONCLUSION

Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.     

Single-Incision Laparoscopic Combined Cholecystectomy and Appendectomy

Background and Objectives:

Single-incision laparoscopic surgery is becoming more widely used, but few combined procedures have been reported. Herein we share our experience with single-incision laparoscopic combined cholecystectomy and appendectomy.

Methods:

We reviewed data from 26 patients who underwent single-incision laparoscopic combined cholecystectomy and appendectomy between May 1, 2009 and June 1, 2013 at Shengjing Hospital. All the procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

Results:

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

Conclusions:

Single-incision laparoscopic combined cholecystectomy and appendectomy appear to be a technically feasible alternative to the standard laparoscopic procedure in simultaneous management of coexisting benign gallbladder and appendix pathologies. Larger studies are required to confirm these findings.     

Single-incision versus conventional laparoscopic appendectomy in 688 patients: a retrospective comparative analysis

Background

Laparoscopic surgery has become the standard for treating appendicitis. The cosmetic benefits of using single-incision laparoscopy are well known, but its duration, complications and time to recovery have not been well documented. We compared 2 laparoscopic approaches for treating appendicitis and evaluated postoperative pain, complications and time to full recovery.

Methods

We retrospectively reviewed the cases of consecutive patients with appendicitis and compared those who underwent conventional laparoscopic appendectomy (CLA) performed using 3 incisions and those who underwent single-incision laparoscopic appendectomy (SILA). During SILA, the single port was prepared to increase visibility of the operative site.

Results

Our analysis included 688 consecutive patients: 618 who underwent CLA and 70 who underwent SILA. Postsurgical complications occurred more frequently in the CLA than the SILA group (18.1% v. 7.1%, p = 0.018). Patients who underwent SILA returned to oral feeding sooner than those who underwent CLA (median 12 h v. 22 h, p < 0.001). These between-group differences remained significant after controlling for other factors. Direct comparison of only nonperforated cases, which was determined by pathological examination, revealed that SILA was significantly longer than CLA (60 min v. 50 min, p < 0.001). Patients who underwent SILA had longer in-hospital stays than those who underwent CLA (72 v. 55 h, p < 0.001); however, they had significantly fewer complications (3.0% v. 14.4%, p = 0.006).

Conclusion

In addition to its cosmetic advantages, SILA led to rapid recovery and no increase in postsurgical pain or complications.     

Transumbilical Single-Incision Laparoscopic Resection of Focal Hepatic Lesions

Background and Objectives:

Transumbilical single-incision laparoscopic surgery (SILS) is gaining in popularity as a minimally invasive technique. The reduced pain and superior cosmetic appearance it affords make it attractive to many patients. For this study, we focused on SILS, analyzing the outcomes of transumbilical single-incision laparoscopic liver resection (SILLR) achieved at our institution between January 2010 and February 2013.

Patients and Methods:

Pre- and postoperative data from 17 patients subjected to transumbilical SILLR for various hepatic lesions (8 hemangiomas, 2 hepatocellular carcinomas, 2 metastases, 2 calculi of left intrahepatic duct, and 3 adenomas) were assessed. Altogether, eight wedge resections, seven left lateral lobectomies, a combination wedge resection/left lateral lobectomy, and a proximal left hemihepatectomy segmentectomy were performed, as well as four simultaneous laparoscopic cholecystectomies. In each instance, three ports were installed through an umbilical incision. Once vessels and bleeding were controlled, the lesion(s) were resected with 5-mm margins of normal liver. Resected tissues were then bagged and withdrawn through the umbilical incision. The follow-up period lasted for a minimum of 6 months.

Results:

All 17 patients were successfully treated through a single umbilical incision. The procedures required 55 to 185 minutes to complete, with blood loss of 30 to 830 mL. Subjects regained bowel activity 0.8 to 2.3 days postoperatively and were discharged after 3 to 10 days. There were few complications (23.5%), limited to pleural effusion, wound infection, and incisional hernia.

Conclusions:

Transumbilical SILLR is challenging to perform through conventional laparoscopic instrumentation. The risk of bleeding and technical difficulties is high for lesions of the posterosuperior hepatic segment. Surgical candidates should be carefully selected to optimize the benefits of this technique.     

Incidence of Port-Site Incisional Hernia After Single-Incision Laparoscopic Surgery

Background and Objectives:

Single-incision laparoscopic surgery is gaining popularity among minimally invasive surgeons and is now being applied to a broad number of surgical procedures. Although this technique uses only 1 port, the diameter of the incision is larger than in standard laparoscopic surgery. The long-term incidence of port-site hernias after single-incision laparoscopic surgery has yet to be determined.

Methods:

All patients who underwent a single-incision laparoscopic surgical procedure from May 2008 through May 2009 were included in the study. Single-incision laparoscopic surgical operations were performed either by a multiport technique or with a 3-trocar single-incision laparoscopic surgery port. The patients were seen at 30 to 36 months'' follow-up, at which time they were examined for any evidence of port-site incisional hernia. Patients found to have hernias on clinical examination underwent repairs with mesh.

Results:

A total of 211 patients met the criteria for inclusion in the study. The types of operations included were cholecystectomy, appendectomy, sleeve gastrectomy, gastric banding, Nissen fundoplication, colectomy, and gastrojejunostomy. We found a port-site hernia rate of 2.9% at 30 to 36 months'' follow-up.

Conclusion:

Port-site incisional hernia after single-incision laparoscopic surgical procedures remains a major setback for patients. The true incidence remains largely unknown because most patients are asymptomatic and therefore do not seek surgical aid.     

SINGLE-INCISION VIDEOLAPAROSCOPIC APPENDECTOMY WITH CONVENTIONAL VIDEOLAPAROSCOPY EQUIPMENT

Background

Acute appendicitis is the most common surgical emergency in daily practice, and is approached laparoscopically in many centers. Efforts have been undertaken for the development of minimally invasive techniques that reduce tissue trauma and offer improved cosmetic results, one of such being the single-incision laparoscopic surgery (SILS).

Aim

To present a minimally invasive technique for appendectomy (SILS) undertaken with conventional instruments.

Method

Eleven patients were treated in the emergency care center presenting abdominal pain in the right iliac fossa that was suggestive of appendicitis. Diagnostic investigation was subsequently conducted, including physical examination, laboratory and imaging exams (CT scan with intravenous contrast or total abdominal ultrasound), and the results were consistent with acute appendicitis. Thus, after consent, these patients underwent SILS appendectomy under general anesthesia with three trocars (two 10 mm and one 5 mm), using conventional and optical laparoscopic tweezers (10 mm, 30º). The base and pedicle of the appendix were ligated with titanium LT 400 clips. The procedure occurred uneventfully. Inclusion criteria were absence of diffuse peritonitis, BMI (body mass index) less than 35 and absence of serious comorbidities or sepsis.

Results

Seven men and four women were operated with average age of 25.7 years and underwent appendectomy through this technique. Mean procedure duration was of 37.2 min. Regarding surgical findings, three had appendicitis in stage 1, four in stage 2 and four in stage 3. All patients improved well, without surgical complications, and did not require conversion to open surgery or conventional laparoscopy technique.

Conclusion

Appendectomy conducted through Single Incision Laparoscopic Surgery is a feasible and promising technique that can be performed with conventional laparoscopic instruments.     

Single-Site Nissen Fundoplication Versus Laparoscopic Nissen Fundoplication

Background:

Advances in minimally invasive surgery have led to the emergence of single-incision laparoscopic surgery (SILS). The purpose of this study is to assess the feasibility of SILS Nissen fundoplication and compare its outcomes with traditional laparoscopic Nissen fundoplication.

Methods:

This is a retrospective study of 33 patients who underwent Nissen fundoplication between January 2009 and September 2010.

Results:

There were 15 SILS and 18 traditional laparoscopic Nissen fundoplication procedures performed. The mean operative time was 129 and 182 minutes in the traditional laparoscopic and single-incision groups, respectively (P = .019). There were no conversions in the traditional laparoscopic group, whereas 6 of the 15 patients in the SILS group required conversion by insertion of 2 to 4 additional ports (P = .0004). At short-term follow-up, recurrence rates were similar between both groups. To date, there have been no reoperations.

Conclusions:

SILS Nissen fundoplication is both safe and feasible. Short-term outcomes are comparable with standard laparoscopic Nissen fundoplication. Challenges related to the single-incision Nissen fundoplication include overcoming the lengthy learning curve and decreasing the need for additional trocars.     

Cost Assessment of Instruments for Single-Incision Laparoscopic Cholecystectomy

Background and Objectives:

Specially designed surgical instruments have been developed for single-incision laparoscopic surgery, but high instrument costs may impede the implementation of these procedures. The aim of this study was to compare the cost of operative implements used for elective cholecystectomy performed as conventional laparoscopic 4-port cholecystectomy or as single-incision laparoscopic cholecystectomy.

Methods:

Two consecutive series of patients undergoing single-incision laparoscopic cholecystectomy were assessed: (1) single-incision cholecystectomy using a commercially available multichannel port (n=80) and (2) a modified single-incision cholecystectomy using 2 regular trocars inserted through the umbilicus (n=20) with transabdominal sutures for gallbladder mobilization (puppeteering technique). Patients who underwent conventional 4-port cholecystectomy during the same time period (n=100) were selected as controls.

Results:

The instrumental cost of the single-incision cholecystectomy using a commercial port was significantly higher (median, $1123) than the cost for conventional 4-port (median $441, P < .0005) and modified single-incision cholecystectomy (median $342, P < .0005). The cost of the modified single-incision procedure was significantly lower than that for the 4-port cholecystectomy (P < .0005).

Conclusion:

The modified single-incision procedure using 2 regular ports inserted through the umbilicus can be performed at lower cost than conventional 4-port cholecystectomy.     

Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation—A rare case

INTRODUCTION

Chilaiditi''s syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi''s syndrome in association with intestinal malrotation and this case study describes its successful management.

PRESENTATION OF CASE

An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic.

DISCUSSION

In nine of the previously reported cases of Chilaiditi''s syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management.

CONCLUSION

Chilaiditi''s syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.     

Laparoscopic Transumbilical Cholecystectomy: Surgical Technique

Background:

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports.

Methods:

The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval.

Results:

Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m². The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours.

Conclusion:

Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.     

Urachal Adenocarcinoma: Incidental Finding at the Time of Surgery for Ruptured Appendicitis

Background:

The urachus is a vestigial structure between the dome of the bladder and the umbilicus. Tumors may develop from the remnants, most of which are well-differentiated, mucinous adenocarcinomas. Urachal adenocarcinoma is an exceedingly rare type of tumor.

Methods:

We present a case of a 51-year-old female presenting to our institution with complaints of abdominal pain for 36 hours. The patient was taken to the operating room for an acute appendicitis. Laparoscopy was performed, and gross purulence and appendiceal perforation were noted as well as a mass on the anterior abdominal wall. Based on the location of the mass, we converted to an open midline laparotomy to treat both the perforated appendicitis and to remove the mass.

Results:

Pathology confirmed the diagnosis of perforated appendicitis and a mucinous-producing urachal adeno-carcinoma.

Discussion:

Data support both open and laparoscopic approaches for appendicitis. This case, although rare, highlights the importance of laparoscopy in a complete and thorough examination of the abdominal cavity. A standard right lower quadrant incision for an open technique would likely have resulted in omission of this lesion, and the patient would have presented at a more typical late stage of her cancer development with significantly more morbidity.     

Granulomatous Peritonitis After Laparoscopic Cholecystectomy

Background:

Granulomatous peritonitis may indicate a number of infectious, malignant, and idiopathic inflammatory conditions. It is a very rare postoperative complication, which is thought to reflect a delayed cell-mediated response to cornstarch from surgical glove powder in susceptible individuals. This mechanism, however, is much more likely to occur with open abdominal surgery when compared with the laparoscopic technique.

Methods:

We report a case of sterile granulomatous peritonitis in an 80-y-old female after a laparoscopic cholecystectomy. Management was conservative, and no relapse was observed after over 1-y of follow-up.

Discussion:

We propose that peritoneal exposure to bile acids during the laparoscopic removal of the gallbladder was the trigger of granulomatous peritonitis in this patient. Severe complications, such as peritoneal adhesions, intestinal obstruction, and fistula formation, were observed, but no fatalities were reported.

Conclusion:

We should be aware of this rare cause of peritonitis in the surgical setting.     

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy

Background and Objectives:

Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations.

Methods:

We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation.

Results:

After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface.

Conclusion:

Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.     

A Comparison of Laparoscopic and Open Appendectomy

Background and Objectives:

To compare laparoscopic appendectomy with traditional open appendectomy.

Methods:

Seventy-one patients requiring operative intervention for suspected acute appendicitis were prospectively compared. Thirty-seven patients underwent laparoscopic appendectomy, and 34 had open appendectomy through a right lower quadrant incision. Length of surgery, postoperative morbidity and length of postoperative stay (LOS) were recorded. Both groups were similar with regard to age, gender, height, weight, fever, leukocytosis, and incidence of normal vs. gangrenous or perforated appendix.

Results:

Mean LOS was significantly shorter for patients with acute suppurative appendicitis who underwent laparoscopic appendectomy (2.5 days vs. 4.0 days, p<0.01). Mean LOS was no different when patients classified as having gangrenous or perforated appendicitis were included in the analysis (3.7 days vs. 4.1 days, P=0.11). The laparoscopy group had significantly longer surgery times (72 min vs. 58 min, p<0.001). There was no significant difference in the incidence of postoperative morbidity.

Conclusions:

Laparoscopic appendectomy reduces LOS as compared with the traditional open technique in patients with acute suppurative appendicitis. The longer operative time for the laparoscopic approach in our study is likely related to the learning curve associated with the procedure and did not increase morbidity.     

Single-Incision Versus Conventional Laparoscopic Adjustable Gastric Banding

Background and Objectives:

Laparoscopic adjustable gastric banding is an effective and popular bariatric surgery for weight loss in obese patients that traditionally involves up to 5 incisions. Recently, a more minimally invasive single-incision technique has been developed. In this retrospective study, we compare conventional and single-incision laparoscopic adjustable gastric banding with regard to weight loss and complication rates in a cohort of demographically similar patients.

Methods:

From February 2009 to February 2010, 59 patients underwent laparoscopic adjustable gastric banding by one surgeon at an outpatient surgery center. All patients were compared by age, sex, preoperative body mass index, 30-day complication rates, and excess weight loss. Thirty-seven operations were performed by a conventional, 5-incision technique, whereas 22 patients underwent the single-incision technique. The success of these techniques was determined by comparing complication rates and average percentage excess weight loss at 6-month follow-up intervals.

Results:

Patients who underwent conventional laparoscopic adjustable gastric banding had a mean age of 41.2 years and preoperative body mass index of 48.2 kg/m² compared with 43.9 years and 40.3 kg/m², respectively, for the single-incision patients. The mean operative time in the single-incision group was longer than that in the conventional group: 47.1 minutes versus 37.4 minutes (P = .0027). The overall percentage excess weight loss was not statistically different between the 2 groups for each follow-up period. There were no complications or deaths in either group.

Conclusion:

Although patients undergoing bariatric surgery may choose the single-incision technique for cosmetic purposes, this retrospective review comparing single-incision and conventional laparoscopic adjustable gastric banding shows longer operative times with equivalent weight loss and morbidity.     

Laparoscopic Repair of a Right Paraduodenal Hernia

Background and Objectives:

Right paraduodenal hernia (PDH) results from a primitive gut malrotation. The resultant jejunal mesenteric defect posterior to the superior mesenteric vessels allows decompressed jejunum to herniate retroperitoneally. PDH make up 53% of all internal hernias, but account for only 0.2% to 5.8% of all cases of intestinal obstruction. In addition, PDH exhibits male and left-sided predominance. Ours is the second report to describe the preoperative diagnosis and totally laparoscopic repair of a right PDH.

Methods:

We report the case of a 26-year-old female with symptoms suggestive of partial small bowel obstruction and a 6-year history of intermittent abdominal pain. Physical examination demonstrated lower quadrant tenderness. Plain abdominal radiographs and ultrasonography were nondiagnostic. Contrasted computed tomography of the abdomen revealed jejunum encased within the right upper quadrant suspicious for right PDH.

Results:

The patient underwent successful laparoscopic right PDH repair and was discharged home on postoperative day 1 without late sequelae.

Conclusions:

In the outpatient setting, clinical suspicion and comprehensive radiological investigation permit preoperative diagnosis of right PDH. In acute situations, clinical presentation, plain radiographs, and then diagnostic laparoscopy may be an expeditious diagnostic algorithm. Subsequent laparoscopic repair of right PDH is feasible and may shorten hospital length of stay.