Small bowel obstruction in a lateral trocar site following laparoscopic bariatric surgery

Introduction

One of the complications of laparoscopic surgery is incisional hernia at the port trocar site. It is a rare complication, with a reported incidence varying between 0.65% and 2.8%, and it is documented in both adults and children.

Case presentation

An obese 62-year-old woman underwent a laparoscopic mini gastric bypass for body weight reduction at another hospital. On the third post-operative day, she developed abdominal pain with vomiting and was admitted to our hospital. Imaging studies confirmed a small bowel loop obstruction at the lateral 12mm trocar site and the patient was operated on immediately. The viability of the entrapped bowel was confirmed at the trocar site opening, the bowel loop was returned into the abdominal cavity and the defect was closed. Two days later, the patient was discharged in good condition.

Discussion

Trocar site or port site hernia is defined as an incisional hernia which occurs after minimal invasive surgery, at the trocar site incision. Following bariatric surgery its reported incidence is 1% - 1.6%. Its cause is multi-factorial, including obesity and old age, the size and site of the inserted trocar and the angle of insertion, and excessive manipulations. Although there is no clear consensus on closure at port sites, it is recommended that fascial defects of larger than 10mm in adults and 5mm in children should be closed.

Conclusion

Trocar site hernia is a rare complication of laparoscopic procedures, and one that can be minimized. Viscus entrapment in a port site hernia should be suspected during the post-operative period whenever the patient presents with abdominal distension, pain and vomiting since, particularly in the case of bariatric surgery, the findings on physical examination may be inconclusive, due to obesity.

     

In vitro effect of lemon and orange juices on calcium oxalate crystallization

Aim  In recent years significant progress has been made in identifying and quantitating physico-chemical processes involved in urinary stone formation. The ability of urine to inhibit calcium oxalate crystallization is an important mechanism against stone formation. Dietary factors appear to affect the ability of urine to inhibit calcium oxalate crystallization. These factors encouraged us to study the effects of lemon and orange juices on calcium oxalate crystallization in vitro. Material and methods  The nucleation and aggregation of calcium oxalate monohydrate crystals were studied using turbidimetric 30-min time course measurements of optic density at 620 nm after mixing solutions containing calcium chloride and sodium oxalate at 37°C, pH 5.7. The formation of crystals is induced by the addition of the oxalate and calcium solution. The effects on calcium oxalate crystal growth of trisodium citrate, lemon and orange juices were examined. The effects of lemon and orange juices were evaluated by the addition of 50 ml of juices. The optical density is measured at physiological conditions. The maximum increase of optic density with time, termed S_N, reflects maximum rate of formation of new particles. After an equilibrium has been reached, a progressive decrease of optic density with time is observed. Rate of aggregation, S_A, is derived from the maximum decrease in optic density. Results  Among the modifiers studied, citrate decreased both S_N and S_A (P < 0.001). Lemon juice was also found to inhibit the rate of crystal nucleation and aggregation. But orange juice did not have any effect on the calcium oxalate crystallization (P > 0.05). Conclusion  These results show that effective prevention of urinary stone formation should aim at restoring the urine’s ability to inhibit calcium oxalate crystallization and more emphasis should be given to dietary measures.     

Comparison of digital and plain radiography preoperative templating in total knee arthroplasty

We present the results of prospective evaluation of digital compared to plain radiographic preoperative templating for primary total knee replacement. All consecutive patients undergoing primary knee replacement were eligible. Patients with previous knee replacement or without calibrated digital or plain radiographs were excluded. Plain radiographs were templated against acetate templates. Digital images were templated with the help of commercial software TraumaCad. A 25-mm spherical metal ball placed nearest to the affected knee joint acted as calibration object. The ICC value for intra-rater reliability was 0.846 for tibial templating and 0.840 for femoral templating. PFC sigma cruciate substituting components were implanted in all patients. Twenty-eight consecutive patients between April 2006 and June 2007 were included. Accurate digital templating score was 80% for tibial implant and 40% for femur. Accuracy of analog templating was 55% for tibial implant and 50% for femur. There was no mismatch of over one size. The differences between templated and implanted sizes were plotted against their mean in Bland–Altman plot. The 95% confidence interval of the differences between digital and actual sizes were: 0.78 to −0.75 sizes for tibial implant and 1.15 to −0.93 sizes for femoral implant. The 95% confidence interval of the differences between plain and actual sizes were: 0.38 to −0.99 size for tibial implant and 0.93 to −1.32 size for femoral implant. The two tailed P value for difference between digital and analog templating from a Wilcoxon matched pair signed rank test was 0.021 for tibia and 0.006 for femur. We found preoperative templating by the operating surgeon reliable and accurate but digital templating did not offer any additional advantage.     

Effects of melatonin on spermatogenesis and testicular ischemia-reperfusion injury after unilateral testicular torsion-detorsion

Purpose

This study aimed to determine the effect of melatonin in preventing ischemia-reperfusion (I-R) injury-induced tissue damage and on spermatogenesis after experimental testicular torsion (TT).

Methods

Forty peripubertal rats were divided into 4 groups each containing 10 rats: control (C), sham (S), torsion plus detorsion (TD), and torsion plus melatonin (M). The left testes were rotated 720° for 6 hours and detorsed for 6 hours thereafter. Serum inhibin B (IB) levels were measured in blood samples taken from all groups. Left orchiectomies were performed to determine the tissue levels of Johnsen's scores (JS) and malondialdehyde (MDA).

Results

Serum IB levels in the S and TD groups were significantly lower compared with that in the C group, whereas they were higher in the M group compared with the TD group. The MDA levels were significantly lower in the C, S, and, M groups compared with the TD group. Johnsen's scores were significantly higher in the C, S, and M groups compared with the TD group.

Conclusions

Our results suggested that melatonin is a potent antioxidant agent in preventing testicular I-R injury, as shown by increased IB levels and JS.     

Chronic pseudoaneurysm of the aortic arch: a case report

Pseudoaneurysm of the thoracic aorta is a rare condition and usually occurs following blunt trauma. It is almost fatal in the absence of prompt surgical treatment. We describe the case of a 56-year-old male suffering from intermittent non-massive hemoptysis, mild dysphagia, and atypical chest pain for 1 month who has no history of trauma. A saccular aneurysm at the aortic arch between left common carotid artery and left subclavian artery was diagnosed by magnetic resonance imaging. Intraoperatively, compression of surrounding structures including trachea and esophagus by the aneurysmal sac (6 x 8 cm in diameter) was seen. Pseudoaneurysm adherent to the upper lobe of the left lung was resected and entire aortic arch replacement with a prosthetic graft was performed. Postoperative course was uneventful and neither specific changes on histologic examination nor any evidence of infection could be detected.     

Risk of developing fibroadenoma with the use of cyclosporine A in renal transplant recipients

To investigate the effect of cyclosporine A (Cyc A) on the development of fibroadenomas, 30 renal transplant patients and 20 chronic renal failure patients on dialysis were breast examined with ultrasonography and/or mammography. Of the renal transplant patients, 17 were receiving Cyc A-based combination therapy for immunosuppression. All patients were female with the age range of 29.7+/-9.2 years in the transplant group and 33.95+/-9.91 in the dialysis group. Eight of the 17 patients receiving Cyc A had fibroadenomas, 5 of them having bilateral lesions. None of the other patients, those on dialysis and on non-Cyc A combination therapy had fibroadenomas. A significant difference for fibroadenoma incidence in patients receiving Cyc A combination immunosuppression was found.     

Ultrastructural evaluation of pulsed radiofrequency and conventional radiofrequency lesions in rat sciatic nerve

BackgroundPRF treatment has recently been described as minimally neurodestructive alternative to radiofrequency heat lesions. Patients with some pain syndromes in whom the pain could not be controlled by alternative techniques may be treated using PRF. In the present study, our main goal was to evaluate and compare the ultrastructure of peripheral nerve tissue that was heated by PRF, CRF with 42°C, and CRF with 70°C.MethodsForty-five male rats were divided into 5 groups. In PRF group and CRF with 42°C group, the sciatic nerve was heated at a temperature of 42°C for 120 seconds. As a positive control, some rat sciatic nerves were treated with CRF lesions at 70°C. The rats were kept alive for 21 days and then killed. Tissue was evaluated with transmission electron microscope, and grading was done to the groups.ResultsThe unmyelinated nerve fibers were ultrastructurally normal in all groups. The results of myelinated axons indicated that PRF group had better grades, and CRF with 70°C group had the worst grade. Especially, comparison of the group of PRF and CRF with 42°C revealed significant difference. In PRF group, none of the myelinated axons showed severe degeneration findings, and most of the damaged myelinated axons showed only separation in myelin configuration.ConclusionsPRF treatment may cause separation in myelinated axons. However, it seems that all changes were reversible. The present study supports the hypothesis that pulsed RF treatment does not rely on thermal injury of neurologic tissue to achieve its effect.     

Melatonin prevents acetaminophen-induced nephrotoxicity in rats

Nephrotoxicity is a major complication of acetaminophen (APAP), a widely used analgesic and antipyretic drug, and there is no specific treatment for APAP-induced renal damage. It has been reported that reactive oxygen metabolites or free radicals are important mediators of APAP toxicity. In this study, the protective role of melatonin (MLT) on APAP-induced nephrotoxicity was investigated in rats. For this purpose, nephrotoxicity was induced in male Wistar albino rats by intraperitoneal (i.p.) administration of a single dose of 1,000 mg/kg APAP. Some of these rats also received i.p. melatonin (10 mg/kg) 20 min after administration of APAP. The rats were sacrificed 24 h after administration of APAP. Urea and creatinine levels were measured in the blood, and levels of malondialdehyde (MDA) and glutathione (GSH), and glutathione peroxidase (GSH-Px), catalase (CAT), and superoxide dismutase (SOD) activity were determined in renal tissue. Serum urea and creatinine levels increased significantly as a result of APAP nephrotoxicity. A significant increase in MDA and decreases in GSH level and GSH-Px, CAT, and SOD activity indicated that APAP-induced renal damage was mediated through oxidative stress. Significant beneficial changes were noted in serum and tissue oxidative stress indicators in rats treated with MLT. These biochemical observations were supplemented by histopathological examination of kidney sections, which revealed that MLT also reduced the severity of APAP-induced histological alterations in the kidney. These results indicate that administration of APAP causes oxidative stress to renal tissue and that MLT protects against the oxidative damage associated with APAP.     

Auto-circler device (Tercan device) for marking a vertical scar mammaplasty

It is known that the desired shape and position of the nipple–areola complex may be difficult to achieve in vertical-scar reduction mammaplasty. The marking of a mosque-shaped areolar pattern varies from one surgeon to another, and therefore, periareolar trimming or resection may be inevitable with the use of such technique. We have developed a device to standardize the periareolar marking, and reduce the irregularity of the periareolar region. This device mimics the elasticity of normal breast tissue, and has the flexibility to be applicable to all breast types. We believe that this device improves the results of vertical-scar reduction mammaplasty and can eliminate the necessity of “last-minute” modifications intraoperatively.