Laparoscopic Management Research Articles

A method of laparoscopic treatment of large adnexal cysts - Two port trocar suction.

The size of the adnexal cyst is a limitation to perform laparoscopic adnexal surgery. Large adnexal cysts may constrain the surgery space and may increase the risk of inadvertent cyst rupture during the surgery. Here, we offer a method to solve the difficulty in laparoscopic management of large adnexal cysts. This is a retrospective study of 43 patients with large (≧10cm) adnexal cysts, managed laparoscopically at one center from October 2016 to October 2019. All the surgeries were performed by an experienced laparoscopic surgeon. Malignancy was excluded before the surgeries according to the sonographic features. Cystectomy or salpingo-oophorectomy was decided according to the age, the sonographic pattern of the cyst and the patients' willingness. A 2cm vertical incision was made at the umbilicus, and an open laparoscopy method was used to enter the peritoneal cavity. A wound protector was applied with a glove and two trocars being set up. The second wound was made at the left abdomen, and a 5mm trocar was inserted. Then the cyst was punctured by means of the 5mm trocar, and the content of the cyst was then soon aspirated by means of the air-flow hole of the trocar. Afterward, cystectomy or salpingo-oophorectomy was performed. Data are expressed as mean±standard deviation unless stated otherwise. The mean operative duration was 54.7±33.4min, and the result was shorter than the previous study (P<0.05, CI (-32.92,-12.38)) according to one sample t-test. Most estimated blood loss (EBL) was minimum. No obvious complication was found. Two-port trocar suction in laparoscopic management of large adnexal cysts is feasible after proper evaluation, and it takes short operative time.

Laparoscopic management of ovarian torsion in the third trimester of pregnancy

Laparoscopic management of ovarian torsion in the third trimester of pregnancy

Laparoscopy versus open surgery for the surgical management of tubo-ovarian abscess (TOA). Is there a beneficial impact of early endoscopic intervention in terms of fertility rates?

To compare success rates and complications in women undergoing laparoscopic versus open surgical management of tubo-ovarian abscess. We further examined whether early laparoscopic intervention has any impact on pregnancy rates in a subgroup of infertile patients following frozen-thawed embryo transfer. Hospital records of 48 patients diagnosed with TOA between January 2015 and December 2020, who underwent surgical intervention or received only medical treatment were analyzed. All patients were hospitalized, and parenteral antibiotics were commenced on admission initially. Laparoscopic or open surgery was performed within 48 hours course of intravenous antibiotherapy (early intervention) or later according to the clinical findings and antibiotherapy response. Of 48 patients with TOA, 18 (37.5%) underwent laparoscopic and 30 (62.5%) underwent open surgical intervention. The median postoperative hospital stay was shorter (4.5 days vs 7.5 days, respectively; p = 0.035), and postoperative opioid analgesic requirement was lesser in the laparoscopy group compared to open surgery group (22% vs 53%, respectively; p = 0.034). Intra- and post-operative complication rates were similar between the groups. Of these 48 patients, seven were diagnosed to have TOA following oocyte retrieval, and four of these conceived with frozen thawed embryo transfer all of whom underwent laparoscopic surgery within 48 hours of diagnosis. Minimal invasive surgery should be preferred even in the presence of severely adhesive and inflammatory TOA in order to improve postoperative outcomes. Moreover, early laparoscopic intervention may be considered in infertile patients with an aim to optimize pregnancy rates in a subsequent frozen-thawed embryo transfer.

Laparoscopic Management of Perforated Meckel's Diverticulitis in Pregnancy

A 39-year-old woman gravida 3 para 2, presented to the emergency room at 19+6 weeks gestation with epigastric pain and nausea. A 4-cm right ovarian cyst was reported on magnetic resonance imaging, and a cyst torsion was suspected. Laparoscopy was performed, with an open transumbilical port established by and a retractor-and-glove system used as previously reported [1]. The cyst was not torted, however, a segment of swollen small intestine was adherent to anterior abdominal wall above the gravid uterus, with surrounding pus and fibrin. This was consistent with the site of abdominal pain (Fig. 1). On further inspection a small bowel perforation was noted in a diverticulum following laparoscopic adhesiolysis (Fig. 2A). The small bowel was delivered through the umbilical wound, with wide-based Meckel's diverticulitis (MD) noted at 40 cm proximal to the ileocecal valve (Fig. 2B, white arrow). An uncomplicated diverticulectomy was performed, and the patient recovered uneventfully. Fig. 2(A) An outpouching of the small intestine was noted after adhesiolysis. (B) By pulling out the related segments of small bowels through the umbilical wound, a perforated Meckel's diverticulitis was noted at 40 cm proximal to the ileocecal valve. White arrow indicates the Meckel's diverticulum. View Large Image Figure Viewer Download Hi-res image

Laparoscopic vs Endoscopic Management of Pancreatic Pseudocysts: A Scoping Review.

Pancreatic pseudocyst (PPC) and walled-off necrosis (WON) develop as late complications of acute pancreatitis that have been historically managed surgically. With the advancement in endoscopic equipment and the evolution of endoscopic surgery, the management of PPC has evolved considerably in recent years from surgical drainage to transmural endoscopic drainage. Till the end of the 20th century, a limited number of surgeons performed laparoscopic drainage of PPCs. Due to the steep learning curve needed for performing advanced laparoscopic suturing, a majority of studiesconducted during this period have compared open surgical drainage with endoscopy.The efficacy of these modalities has largely been evaluated using retrospective studies and a few meta-analysesparticularly due to the low-volume caseload of individual centres. Also, these studies include PPC and WON together in data analysis despite WON being a distinct entity. There are limited prospective well-designed clinical trials comparing endoscopic and laparoscopic management of pure PPCs. There is also a lack ofspecific recommendations for the management of PPCs. Considerable overlap of indications between these two modalitiesexists. The efficacy of endoscopic transmural drainage as an index intervention when compared to laparoscopy has not been proven in the research literature. Previous studies have not considered multiple endoscopic interventions within a four-week period of index intervention as a failure.We reviewed the literature using appropriate MeSH terms on the PubMed search engine for articles comparing laparoscopic and endoscopic transmural management of PPCs according to our inclusion and exclusion criteria. Seven articles were identified for inclusion in the qualitative synthesis. This scoping review was conducted to answer some pertinent unanswered questions, identify gaps in knowledge regarding the laparoscopic vs endoscopic management of PPCs, and guide further research.

Evaluation of Intraoperative Operative Parameters and Postoperative Complications in Laparoscopic Management of Complicated Appendicitis

Evaluation of Intraoperative Operative Parameters and Postoperative Complications in Laparoscopic Management of Complicated Appendicitis

Optimal surgical approaches for esophageal epiphrenic diverticulum: literature review and our experience

Esophageal epiphrenic diverticulum is a rare condition usually secondary to a primary esophageal motility disorder. Although epiphrenic diverticulum may be treated by thoracoscopic and laparoscopic management, the optimal surgical approach have not been established. We successfully treated a left epiphrenic diverticulum along with achalasia and paraesophageal hernia by a planned combination of thoracoscopic and laparoscopic procedures aided by preoperative simulation using three-dimensional imaging. We reviewed a series of 17 reports on esophageal epiphrenic diverticulum that required either planned or unplanned unexpected transthoracic surgery. The main reasons for requiring a transthoracic approach were adhesions, site and size of the diverticulum, and length of the diverticulum neck. Unplanned procedure changes were required in 12 of the 114 cases for a conversion rate of 10.5%. Diverticulectomy, myotomy, and fundoplication were the most common surgical treatments administered at 42.6%. Based on literature review and our experience, we have developed a flowchart to identify the characteristics of epiphrenic diverticulum cases that require a transthoracic approach. This flowchart can help to determine therapeutic strategies and the optimal surgical approach to esophageal epiphrenic diverticulum treatment and may reduce unplanned changes in the surgery.

Laparoscopic management of Mirizzi syndrome with liver cirrhosis using indocyanine green mapping: A case report and review of the literature

Laparoscopic management of Mirizzi syndrome with liver cirrhosis using indocyanine green mapping: A case report and review of the literature

Robotic-assisted laparoscopic management of mesenteric cysts in children.

Mesenteric cysts (MCs) are rare intra-abdominal masses in children, and laparoscopic complete cyst resection is still difficult. This study reviewed our experience in diagnosing and managing MCs at our center, focusing on the clinical characteristics of MCs and the effectiveness of robotic-assisted laparoscopic surgery. We conducted a retrospective analysis of the records of all patients diagnosed with MCs and managed with robotic-assisted laparoscopic surgery at our center between February 2021 and August 2022. We analyzed demographic characteristics, clinical manifestations, preoperative imaging data, surgical methods, postoperative complications, and final outcomes. Totally, 12 consecutive patients with a mean age of 5.81 ± 3.02 years were admitted. The most common symptom was abdominal pain (58.33%). Eight patients were associated with cyst complications, including five cases of infection, two cases of volvulus, and one case of hemorrhage. The mean size of cysts was 8.39 ± 5.91 cm. The cysts were located in ileal mesentery in eight cases, lesser curvature of the stomach in two cases, and colon mesentery in two cases. Solely cyst excision was performed in eight cases, and bowel en bloc resection of the cyst in four cases. Robotic-assisted laparoscopic surgery was performed successfully in all patients, without conversion. The mean operation time was 106.17 ± 33.74 min. Pathological results reported lymphangioma or lymphatic malformation in all patients. Two cases of chylous leakage were treated conservatively, and no complications of peritoneal infection, anastomotic leakage, and recurrence were observed. Mesenteric cysts should be removed promptly once the diagnosis is confirmed to avoid cyst complications. For uncomplicated mesenteric cysts, laparoscopic cyst excision, or cyst excision with bowel resection can be effectively performed in children, especially under the robot system.

Incidental gall bladder cancer in the laparoscopic treatment and magnetic resonance imaging era: A single institution experience.

Incidental gall bladder cancer (IGBC) is often discovered unexpectedly in patients after cholecystectomy. Currently, magnetic resonance imaging (MRI) has been widely applied in the pre-operative diagnosis of gall bladder diseases as laparoscopic cholecystectomy developed into the preferred method. This study aimed to evaluate the pre-operative MRI application and laparoscopic management in the IGBCs. Between January 2011 and January 2020, a total of 7917 patients with gall bladder diseases treated by laparoscopy were enrolled in this study. Amongst 49 patients diagnosed with IGBCs, the incidence of IGBCs in polypoid lesions, biliary pancreatitis, cholecystitis, cholecystocholedocholithiasis and gall bladder stones was 0.42%, 1.19%, 0.62%, 1.20% and 0.49%, respectively. MRI evaluation showed more remarkable pre-operative imaging as compared to ultrasonographic evaluation (40.8 vs. 26.5, P < 0.05). Furthermore, 14 patients were diagnosed with gall bladder cancer through intraoperative histological examination and 11 received laparoscopic extensive resection after cholecystectomy. MRI findings with diffuse thickening of the gall bladder detected IGBCs with 6.1% sensitivity, 96.02 specificity, 0.95% positive predictive values and 99.4% negative predictive values; diffuse thickening of the gall bladder with suspicion of malignancy detected IGBCs with 12.2% sensitivity, 99.1% specificity, 7.6% positive predictive values and 99.5% negative predictive values; focal thickening of the gall bladder detected IGBCs with 16% sensitivity, 99.8% specificity, 32% positive predictive values and 99.5% negative predictive values; moreover, suspicious lesion detected IGBCs with 6.1% sensitivity, 99.6% specificity, 8.8% positive predictive values and 99.4% negative predictive values. Patients with biliary pancreatitis and cholecystocholedocholithiasis have a higher incidence of IGBC. MRI evaluation could provide more accurate information for the IGBCs, which should be recommended for patients accepting cholecystectomy. MRI findings exhibited an unsatisfactory sensitivity when detecting IGBCs, but they represented high specificity. Pre-operative MRI evaluation and intraoperative histological examination may help some IGBCs to achieve one-stage laparoscopic extensive resection.

Laparoscopic Approach for the Management of Ectopic Pregnancy in a District Level Hospital, Cox's Bazar

Introduction: An ectopic pregnancy occurs when a fertilized egg implants and grows outside of the uterine cavity. Ectopic pregnancy usually occurs as a result of delay or prevention in the passage of the blastocyst to the uterine cavity resulting in its premature implantation in the extrauterine tissues. It usually occurs in 2% of all pregnancies and is a major cause of maternal morbidity and mortality when misdiagnosed or left untreated and subsequent successful pregnancy is less than 50% of patients. About 95% of ectopic pregnancies originate in the tubes. Infrequently, it affects the ovary, the bicornuate uterus, and the cervix. The diagnosis of ectopic pregnancy has been performed using laparoscopy. Additionally, it is widely used for the surgical treatment of ectopic pregnancy. The benefit of laparoscopy for ectopic pregnancy over laparotomy is well-known. Laparoscopic surgery has been widely adopted and new technical innovations, procedures, and evidence-based knowledge are persistently emerging. The laparoscopic advantage over open surgery has also been confirmed in different fields. It is associated with shorter operative time, less intraoperative blood loss, reduce postoperative pain, less analgesic requirement, a shorter hospital stay, faster recovery, cost- effectiveness, and lower rate of postoperative complications. This study aimed to compare the outcome of laparoscopic management with laparotomy in the management of ectopic pregnancy. Methods: This was a prospective cross-sectional study that was carried out in a district level hospital at Cox's Bazar. This study was conducted from May 2020 to May 2022. A total of 59 subjects were selected for the study as per inclusion criteria. Result: Among 59 respondents, most of the subjects were of the 15-25 years age group which constituted 81.36%, followed by 13.56% of the 26-35 years age group, and the rest 5.08% were of &gt;35 years age group. Laparoscopy was done on 40 (67.20%) patients and laparotomy was done on 19 (32.80%) patients. Approximately, 25% of laparoscopy patients and 52% of laparotomy patients had prior surgery. Prior ectopic surgery was performed on around 8.47% of laparoscopy patients and 13.55% of laparotomy patients. Regarding the comparison of laparoscopy and laparotomy procedure, total blood loss was less (30-50ml) in laparoscopy and more (≥60ml) in the laparotomy procedure. Hospital stay was also less (1-2 days) in laparoscopy and more (≥3 days) in laparotomy, duration of operation was shorter (20-30min) in laparotomy and comparatively longer (30- 60 min) in laparoscopy. Previous surgery was done on 25% and 52.17% patients who underwent laparoscopy and laparotomy respectively. Previous ectopic pregnancy was diagnosed on 8.33% and 47.83% of laparoscopy and laparotomy patients respectively. Moreover, previous PID was found in 5.55% patients who underwent laparoscopy and none who underwent laparotomy. 2.77% of patients who underwent laparoscopy had a history endometriosis. Recovery to normal activity was early in laparoscopy and late in laparotomy. Moreover, 27 (67.5%) patients conceived among 40 who underwent laparoscopy, and 3 (15.78%) patients conceived among 19 who underwent laparotomy. Conclusion: The management of ectopic pregnancy with laparoscopy may be the most helpful operation with the highest possible level of safety and effectiveness. Laparoscopy has both a diagnostic &amp; therapeutic role in ectopic pregnancy. Laparoscopy is feasible and safer than laparotomy in surgical management of ectopic pregnancy.

Postoperative Pregnancy Outcomes Following Laparoscopic Surgical Management in Women with Stage III/IV Endometriosis: A Single-Center Follow-Up Study.

The effects of laparoscopic surgical management in women with stage III/IV endometriosis remain controversial. The standard extent of resection for stage III/IV endometriosis with deep endometriosis to treat endometriosis-associated infertility is debatable. This study aimed to assess the postoperative pregnancy outcomes following a routine surgical intervention for stage III/IV endometriosis patients. Patients with stage III/IV endometriosis who underwent conservative laparoscopic surgery at our hospital between January 2010 and December 2018 were retrospectively analyzed. Statistical analyses were performed to determine the correlations between endometriosis features and postoperative pregnancy outcomes. Of 256 patients enrolled, 94 wished to conceive. Exclusion criteria: ≥40 years, adenomyosis, partners with infertility issues. Finally, 71 women were included. The overall postoperative pregnancy rate was 76.1% (n = 54): 49 and five from non-assisted reproductive technology (ART) and ART, respectively. The postoperative pregnancy rate in patients diagnosed with infertility presurgery (40/71) was 70.0% (n = 28): 24 (non-ART) and four (ART). The endometriosis fertility index (EFI) score was higher in the pregnant than in the nonpregnant group (P = 0.03). The EFI score and surgical score of EFI were higher in the non-ART than in the ART group (P = 0.04; P = 0.02); in the infertile group, they were higher in the pregnant than in the nonpregnant group (P = 0.018; P = 0.027). Our postoperative pregnancy rate after conservative laparoscopic surgery for patients with stage III/IV endometriosis compared favorably with previous reports. EFI was a significant predictor of postoperative pregnancy. Our surgical approach to maintain a high surgical score of EFI might help treat endometriosis-associated infertility.

Laparoscopic Management of Blunt Pancreatic Trauma in Adults and Pediatric Patients: A Systematic Review.

Pancreatic trauma is an uncommon injury that occurs usually in a young population and is frequently overlooked and not readily appreciated on initial examination. Nowadays, the diagnosis and management of pancreatic trauma are still controversial, and there is no gold standard for the treatment. The aim of this study is to describe our experience in the management of blunt pancreatic trauma with a laparoscopic approach and review the literature on laparoscopic management of pancreatic trauma. A systematic literature review was performed, and 40 cases were reported and analysed; 10 cases were excluded because the complete data were not retrievable. We also reported our experience with the case of an 18-year-old male diagnosed with a deep laceration of the pancreas between body and tail, involving the main pancreatic duct, and with a concomitant hematoma. The patient underwent exploratory laparoscopy with abdominal toilet, necrosectomy, and suture of main pancreatic duct; the total blood loss was less than 200 ml, and the total operative time was 180 minutes. The patient recovered uneventfully and was discharged on the 6th postoperative day. 30 patients with pancreatic trauma, 10 adults and 20 pediatrics (mean age 28.2 years and 10.5 years), underwent a total laparoscopic approach: 2 distal pancreatic-splenectomy, 22 spleen-preserving distal pancreatectomy, and 6 laparoscopic drainage. The mean operative time for the adult and pediatric populations was 160.6 and 214.5 minutes, the mean estimated blood loss was 400 ml and 75 ml, and the mean hospital stay was 14.9 and 9 days, respectively. Laparoscopic management for pancreatic trauma can be considered feasible and safe when performed by an experienced laparoscopic pancreatic team, and in such a setting, it can be considered a viable alternative to open surgery, offering the well-known benefits of minimally invasive surgery.

Comparison between laparoscopic sleeve gastrectomy versus laparoscopic gastric bypass management of type 2 diabetes mellitus obese patients

Comparison between laparoscopic sleeve gastrectomy versus laparoscopic gastric bypass management of type 2 diabetes mellitus obese patients

Laparoscopic versus open surgical management in elderly patients with rectal cancer aged 70 and older.

This retrospective study aimed to compare the short- and long-term surgical outcomes of laparoscopic surgery versus open surgery in elderly patients with rectal cancer. Elderly patients (≥70 years old) with rectal cancer who received radical surgery were retrospectively analysed. Patients were matched (1:1 ratio) using propensity score matching (PSM), with age, sex, body mass index, American Society of Anesthesiologists score and tumour-node-metastasis staging included as covariates. Baseline characteristics, post-operative complications, short- and long-term surgical outcomes and overall survival (OS) were compared between the two matched groups. Sixty-one pairs were selected after PSM. Patients with laparoscopic surgery had a longer duration of operation time, lower estimated blood loss, shorter duration of post-operative analgesics administered, time to first flatus, time to first oral diet and post-operative hospitalisation stay than those observed in patients with open surgery (All P < 0.05). The incidence of post-operative complications in the open surgery group was numerically higher than that occurred in the laparoscopic surgery group (30.6% vs. 17.7%). Median OS was 67.0 months (95% confidence interval [CI], 62.2-71.8) in the laparoscopic surgery group and 65.0 months (95% CI, 59.9-70.1) in the open surgery group, however, Kaplan-Meier curves indicated that no significant differences in OS (Log-rank test, P = 0.535) were noted between the two matched groups. Compared with the open surgery, laparoscopic surgery had the advantages of less trauma and faster recovery, and provided similar long-term prognostic outcome in elderly patients with rectal cancer.

Laparoscopic Surgical Management of an Iatrogenic Tubo-ovarian Abscess Following Hysteroscopy in a Sexually Inexperienced Female.

Laparoscopic Surgical Management of an Iatrogenic Tubo-ovarian Abscess Following Hysteroscopy in a Sexually Inexperienced Female.

The Assessment of the Perioperative Outcome of Laparoscopic versus Open Management of Gastroduodenal Perforation. Our Two-Center Comparative Experience.

The Assessment of the Perioperative Outcome of Laparoscopic versus Open Management of Gastroduodenal Perforation. Our Two-Center Comparative Experience.

Complex Pyogenic Liver Abscess: Outcome of Open vs Laparoscopic Drainage

OBJECTIVES Our study aimed to evaluate the safety and efficacy of laparoscopic drainage as a management of complex pyogenic liver abscesses in comparison to open surgical drainage. METHODOLOGY The comparative research design was used to compare the outcomes, complications, perioperative morbidity, mortality, and potential recurrence of 60 patients with a complex pyogenic liver abscess who were hospitalized at the General Surgery Department of Hayatabad Medical Complex Peshawar and treated either laparoscopically or openly from January 2019 to December 2020. 30 patients had open drainage management, while 30 patients received laparoscopic drainage management. For all patients, pus was examined for culture sensitivity. Patients with a small, solitary and unilocular pyogenic liver abscess that improved with antibiotic therapy and or/and percutaneous drainage were excluded. Each patient had a thorough clinical evaluation, lab tests, ultrasound, computed tomography, or magnetic resonance imaging of the pelvis and abdomen. RESULTS All patients underwent abdominal ultrasonography &amp; sonographic diagnosis was made in 43(71.7%), followed by a computed tomography scan (CT) in 12(20%) &amp; magnetic resonance imaging (MRI) diagnosis was made in 5(8.3%) patients respectively. Diabetes mellitus was present in 15(25%) patients, severe chronic obstructive pulmonary disease in 10(16.7%) and severe anemia in 9(15%) patients. All individuals associated with co-morbidity were considered high-risk patients. CONCLUSION Laparoscopic drainage of liver abscess has a shorter surgical time, lower morbidity rate, and shorter hospital stay as compared to open surgical drainage.

Prospective study of laparoscopic management of appendicitis during the COVID pandemic in a single paediatric centre.

The coronavirus (COVID-19) pandemic affected the presentation of many conditions. This study analyses and describes the impact of the COVID-19 pandemic on the management of appendicitis in children and the role of laparoscopy. We performed a prospective (during the pandemic) and retrospective (historic control) review of the management of appendicitis in a tertiary paediatric surgical unit. Preoperative data, operative findings and patient outcomes were compared between groups to identify differences between the study periods and to identify any factors predictive of outcomes. Sixty-two patients were identified in the pre-pandemic cohort, 72 in the pandemic cohort. There was no significant difference in patient demographics, length of admission or time between admission and surgery between groups. There was however a significantly longer time to presentation to hospital in the pandemic group. Clinical outcomes were comparable between the two groups, with no difference in the presence of surgical complications or histologically advanced appendicitis between the two groups. Laparoscopic surgery was safely used to manage appendicitis in the pandemic cohort through utilisation of a COVID-19 pathway that included guidance on testing, and use of personal protective equipment (PPE). Conservative management in the pandemic cohort was reserved for patients with appendicitis with the presence of mass formation. Despite a delayed presentation to hospital, there was no rise in the incidence of complicated appendicitis, complications of surgery or length of stay during the COVID-19 pandemic. Laparoscopic appendicectomy was also shown to be a safe and effective standard for the management of appendicitis during the pandemic. III, treatment.

Hydrocele of Canal of Nuck In an Adult Female: A Case Report

Hydrocele of the canal of Nuck is a rare abnormality, developing in the protruded part of the parietal peritoneum within the inguinal canal in a female. It is homologous to the processus vaginalis in males and obliterates from the seventh month of gestation to one year of age. Failure of obliteration, results in Nuck hydrocele or herniation of intra-abdominal contents through the patent Canal of Nuck. These are usually detected and repaired in young girls within the first five years of life. Reports of Canal of Nuck hydrocele in adults are sparse. Most of these patients are misdiagnosed on clinical examination and correctly diagnosed intraoperatively during surgery for suspected ‘inguinal hernia’. Here, this case is about a 25-year-old female, who presented with swelling in the right groin for one month. Computed Tomography of the abdomen showed features suggestive of a hydrocele within the Canal of Nuck. She underwent laparoscopic hydrocelectomy and laparoscopic hernia repair via the transabdominal preperitoneal approach. This case report highlights the novel approach of laparoscopic management of this rare case.