Extensive Dense Adhesions Research Articles

Diagnostic Accuracy of Peritoneoscopy to Determine the Cause of Low Serum Ascites Albumin Gradient

Introduction: As cites, a common entity in practice of gastroenterology is path physiologically divided into high SAAG and low SAAG category, to rapidly classify, formulate a workup plan and expedite the diagnosis. The cause of low SAAG as cites is often due to local peritoneal cause e.g. peritoneal tuberculosis, peritoneal carcinomatosis etc, mandating the need of peritoneoscopy for definitive diagnosis. This study aims to present the peritoneoscopy and peritoneal biopsy result of patients with low SAAG as cites of uncertain etiology.
 Methods: Peritoneoscopy was prospectively performed in 12 patients with low SAAG as cites of unclear etiology. Patients with low SAAG as cites and willing to give consent for peritoneoscopy were enrolled in the study. Patients underwent laparoscopic peritoneoscopy under general anesthesia and appropriate biopsies were taken during the procedure for histopathological analysis.
 Results: Of the twelve patients with low SAAG enrolled in the study, 3 (25%) were male and 75% (9) were female. The success rate of the procedure was 100% and there was no procedure related complications. Specific findings were seen in all patients undergoing peritoneoscopy. Of the twelve patients, 9 (75%) patients has metastatic deposits in the peritoneum, 3 (25%) had benign etiology, 2/3rd (2) of whom had granulomatous deposits suggestive of tuberculosis and 1/3rd (1) had extensive dense adhesions and peritoneal fibrosis. Primary focus was revealed (ovary) in only 1 patient undergoing peritoneoscopy.
 Conclusion: Peritoneoscopy with simultaneous biopsy is safe, efficient and accurate diagnostic method due to its high diagnostic capacity and low complication rate in selected patients who have low SAAG as cites of uncertain etiology.

Diagnostic Accuracy of Peritoneoscopy to Determine the Cause of Low Serum Ascites Albumin Gradient

Introduction: Ascites, a common entity in practice of gastroenterology is pathophysiologically divided into high SAAG and low SAAG category, to rapidly classify, formulate a workup plan and expedite the diagnosis. The cause of low SAAG ascites is often due to local peritoneal cause e.g peritoneal tuberculosis, peritoneal carcinomatosis etc, mandating the need of peritoneoscopy for definitive diagnosis. This study aims to present the peritoneoscopy and peritoneal biopsy result of patients with low SAAG ascites of uncertain etiology. Methods: Peritoneoscopy was prospectively performed in 12 patients with low SAAG ascites of unclear etiology. Patients with low SAAG ascites and willing to give consent for peritoneoscopy were enrolled in the study. Patients underwent laparoscopic peritoneoscopy under general anesthesia and appropriate biopsies were taken during the procedure for histopathological analysis. Results: Of the twelve patients with low SAAG enrolled in the study, 3 (25%) were male and 75% (9) were female. The success rate of the procedure was 100% and there was no procedure related complications. Specific findings were seen in all patients undergoing peritoneoscopy. Of the twelve patients, 9 (75%) patients has metastatic deposits in the peritoneum, 3 (25%) had benign etiology, 2/3rd (2) of whom had granulomatous deposits suggestive of tuberculosis and 1/3rd (1) had extensive dense adhesions and peritoneal fibrosis. Primary focus was revealed (ovary) in only 1 patient undergoing peritoneoscopy. Conclusion: Peritoneoscopy with simultaneous biopsy is safe, efficient and accurate diagnostic method due to its high diagnostic capacity and low complication rate in selected patients who have low SAAG ascites of uncertain etiology.

Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience

CONTEXT:Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management.AIMS:Surgical approach has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients.MATERIALS AND METHODS:A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach.RESULTS:The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fistula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period.CONCLUSIONS:Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefits of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.

Laparoscopic completion cholecystectomy: A retrospective study of 40 cases

Throughout the world, laparoscopic cholecystectomy is a widely accepted surgical treatment for both acute and chronic cholecystitis. It provides total relief of pre-surgical symptoms in up to 85% of patients. However, about 5% of patients may experience severe episodes of upper abdominal pain similar to those that they had prior to cholecystectomy; this is known as post-cholecystectomy syndrome. Gallbladder remnant with calculi is one of the causative factors. However, there have been only a few case series related to this reported in literature to date. Herein, we present our experience with laparoscopic management of gallbladder remnant with calculi in 40 cases. A retrospective study of 40 cases was carried out in our institution. All patients underwent open cholecystectomy at other centres, and their cases were managed by laparoscopic completion cholecystectomy. The mean operating time was 102.4 min (range, 60-120 min). The duration of hospital stay was 2-4 days. Two cases were converted to open surgery because of extensive dense adhesions. One case had minor a common bile duct injury, and another had port-site infection. There were no cases of mortality. Gallbladder remnant containing stones may be the cause of otherwise unexplained postcholecystectomy pain. Completion cholecystectomy offers a definitive treatment for any residual gallbladder remnant and can be performed laparoscopically.

Use of Rigid Nephroscope for Laparoscopic Common Bile Duct Exploration—A Single‐Center Experience

Increasingly, laparoscopic biliary surgeons are undertaking laparoscopic cholecystectomy and laparoscopic common bile duct exploration for patients with cholelithiasis and choledocholithiasis. In laparoscopic common bile duct exploration a flexible choledochoscope is ordinarily used, and with this instrument the surgeon usually fails to remove large impacted stones. In contrast with use of a rigid nephroscope it is possible to remove all common bile duct stones irrespective of size and degree of impaction. The present study evaluates the efficiency of rigid nephroscope for managing common bile duct stones laparoscopically. In the present study laparoscopic common bile duct exploration for stones was performed in 80 patients via standard laparoscopic cholecystectomy port sites. Patients with a common bile duct diameter >10 mm were included in this study. The rigid nephroscope was passed through the epigastric port and negotiated into the common bile duct through a choledochotomy. Stones were removed with graspers. Large hard stones were fragmented by pneumatic lithotripsy. Of the 80 patients treated in this manner, 72 (90%) had multiple common bile duct calculi, and 8 (10%) had a solitary common bile duct calculus. Mean common bile duct diameter was 15.3 mm (range: 10-37 mm). Conversion to open common bile duct exploration was necessary in 1 case (1.25%) because of difficult dissection secondary to extensive dense adhesions. In 7 patients (8.75%) a pneumatic lithotripter was used to fragment stones. Choledochotomy was managed by placing a T-tube in 21 (26.25%) patients, by effecting primary closure in 58 (72.5%) patients, and by choledochoduodenostomy in 1 (1.25%) patient. The mean operative time in this series was 83 min (range: 53-135 min). The mean postoperative hospital stay was 4.2 days (range: 3-19 days). One patient (1.25%) developed cholangitis 5 months after laparoscopic common bile duct exploration; the cause was a residual common bile duct stone. A rigid nephroscope can be used for managing all types of common bile duct calculi irrespective of site, size, composition, or degree of impaction. Its use can be expected to become the standard for laparoscopic common bile duct exploration, especially for removing large calculi from a dilated common bile duct.

Audit of laparoscopic cholecystectomy Omdurman teaching hospital

Objectives: To review and audit our experience in laparoscopic cholecystectomy [LC] at Omdurman Teaching Hospital, Sudan. Methods: A prospective study for patients who underwent laparoscopic cholecystectomy in the period, from January 2006 to October 2007. Demographic data, indications for surgery, rate of conversion to open cholecystectomy, morbidity, and mortality rates were noted. Results: A total of 114 patients underwent LC in 21 months, They were female 100 patients and 14 males, age range from 25 to70 years, mean age 44 years. Indications for surgery were biliary colic 65.8%, fatty dyspepsia 37.7%, and acute cholecystitis 3.5%. The range of operative time was 25-90 minutes. Conversion rate was (7.9%). The reasons for conversions were bleeding, extensive dense adhesions, severe inflammation. Conclusion: Our findings were consistent with the literature, demonstrating that LC is a safe minimal invasive technique Keywords: Laparoscopic, cholecystectomy, minimal invasive surgery, surgical audit, Sudan.Sudan Journal of Medical Sciences Vol. 3 (1) 2008: pp. 21-24

O-192: Interceed® vs double layer Surgicell® for prevention of adhesion formation in the rabbit model

Post operative adhesions cause significant morbidity related to small bowel obstruction, chronic pelvic pain and infertility. Interceed, an adhesion barrier composed of oxidized regenerated cellulose (ORC) is shown to decrease adhesion formation significantly in randomized controlled studies, but the cost of the product prevents its widespread use. Surgicell, another product composed of ORC, but marketed as a haemostatic agent, costs approximately 90% less than Interceed. The main difference between two products is Interceed being approximately twice more densely knitted and having smaller pores than Surgicell. Therefore we hypothesized that double layer Surgicell could be as effective as single layer Interceed for preventing adhesions. This study was designed to compare two products in terms of reduction of adhesion formation in the rabbit model. Prospective, randomized, controlled, single blind study. 26 New Zealand White female rabbits of reproductive age were included in the study. Following appropriate anesthesia a midline laparotomy was performed and the ovaries were bivalved with a scalpel. Hemostasis was provided with microbipolar cautery. One of the ovaries was assigned to be covered by a single layer of Interceed® measuring 2cm X 1cm, while the other was assigned to be covered by double layer of Surgicell® of the same size, according to a computer generated randomization table. After the placement, the adhesion barriers were moistened with two drops of sterile normal saline to have them adhered to the ovarian surface. Four weeks later a second look laparotomy was performed and the adhesions were macroscopically scored by an investigator who was blinded to the barrier assignment of the ovaries. Adhesions were scored on a scale of 1 to 4: 1 = no adhesions; 2 = minimal filmy adhesions that were easily separable; 3 = dense adhesions limited to the adnexal area; 4 = extensive dense adhesions, and adhesions of viscera to anterior or posterior abdominal wall. Distribution of adhesions among the groups was compared with chi-square test. 26.9% of the ovaries in both groups had no macroscopic adhesions. While 42.3% of the ovaries in the Interceed group had filmy adhesions that were easily lysed 38.5% of group 2 had adhesions of the same type (p=0.77). Dense adhesions, limited to the adnexal area were present in 19.2% and 26.9% of group1 and group 2 respectively (p=0.51). Widespread adhesion were observed in 11.5% of group 1 and 7.7% of group 2 (p=1). The distribution of adhesions was similar in two groups (Table).Tabled 1 Our results demonstrate that Surgicell, when applied as double layer, is as effective as Interceed in reducing postoperative adhesion formation in the rabbit model. Provided that these results are confirmed in humans the application of Surgicell as an adhesion barrier may be more cost effective.

Laparoscopic Cholecystectomy In The Academy Medicalcentre, Khartoum, Sudan

To highlight the results of minimum access surgery in Sudanese patients. Prospective audit of laparoscopic cholecystectomies. The Academy Medical center (Yastabshiroon), Teaching University Hospital. All the patients who had this type of surgery were included in the study. Clinical and operative data were evacuated from March 2002 to March 2004. One hundred and twenty patients had laparoscopic cholecystectomy at the center. There were 97 females and 23 males; age range was 22-90 years with a mean of 52 years. Indications for surgery were repeated attacks of biliary colic in 38, chronic cholecystitis in 60, acute cholecystis in 10 and mucocele in 12 patients. Three patients with chronic cholecystitis had peri-portal fibrosis due to bilharzial infestations, in spite of which laparoscopic surgery was successful. Operating time was 25-120 minutes with a mean of 47 minutes. Conversion was performed in six (2%) patients because of bleeding and four for extensive dense adhesions. There was one mortality case of a 75-year-old female who had pulmonary embolus. Hospital stay was 16-24 hours with a mean of 22 hours. Two patients had port site discharge. In general, patients were satisfied with the results of surgery and this encourages us to popularise this procedure to take off in the Sudan.