Left Subcostal Region Research Articles

MÚLTIPLOS ABSCESSOS ESPLÊNICOS EM PACIENTE COM CIRROSE HEPÁTICA NO AMAZONAS

A 38-year-old male patient with a diagnosis of liver cirrhosis for 5 years, irregularly treated with lactulose and furosemide, presented with fever, confusion, fatigue, jaundice, and ventilator-dependent pleuritic pain when seeking medical attention. Upon examination, he was lucid but exhibited slowed thinking, a sleep-wake cycle inversion, and flapping. The physical examination revealed edema in the lower limbs, jaundice, and pain in the left subcostal region. Due to the presence of decompensated cirrhosis, monitoring and diagnostic investigation for possible etiologies were initiated. Laboratory tests, ECG, chest X-ray, and echocardiogram were performed. A computed tomography (CT) scan revealed splenomegaly with regular contours and heterogeneous attenuation coefficients, showing hypodense, non-enhancing collections occupying the entire upper half, as well as a left pleural effusion and signs of chronic liver disease and portal hypertension. A transverse incision was made, revealing splenomegaly with the presence of thick fluid collections in the upper pole of the spleen, consistent with a diagnosis of splenic abscess. The patient progressed to hypovolemic shock and underwent reoperation after 72 hours for active bleeding control. Ciprofloxacin and clindamycin were administered for 28 days. The patient improved well after discharge from the ICU, with clinical and laboratory improvement. Follow-up was conducted with amoxicillin 250 mg for two years, and he continues outpatient follow-up with a gastroenterologist. Splenic abscess (SA) usually arises from endocarditis or other forms of hematogenous transmission, such as pneumonias, gastrointestinal perforations, or arteriovenous malformations. Although not always present, risk factors for the development of endocarditis include immunosuppression, diabetes mellitus, trauma, or microorganisms. Diagnosis is based on clinical findings and imaging studies (ultrasound and CT). Treatment depends on the number, size, and location of the abscesses. Antibiotic therapy can drastically reduce mortality associated with this condition, and percutaneous drainage has been successful. However, in some cases, splenectomy is necessary. Splenic abscess is a rare condition, and its early diagnosis requires a high degree of suspicion, and there is still no best approach for treatment.

An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report

BackgroundRobotic-assisted surgery is steadily becoming more prominent. The majority of reports regarding port site hernias (PSHs) have involved laparoscopic procedures. Currently, it is common to suture the fascia at port sites that are 10 mm or larger; however, the closure of 5-mm port sites is not considered mandatory. The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) utilizes a distinctive 8-mm port. We report a case of an early-onset PSH at an 8-mm port site after robotic-assisted ileocecal resection.Case presentationA 74-year-old male patient with a body mass index of 19.7 kg/m2 was diagnosed with cecal cancer and underwent robotic-assisted ileocecal resection. A 3-cm midline incision was made at the umbilicus for insufflation. Under laparoscopic visualization, three ports (12 mm, 8 mm, and 8 mm) were inserted in the lower abdomen. An 8-mm port was inserted in the left subcostal region, and a 5-mm port was inserted in the left lateral abdomen. The procedure was performed without significant intraoperative complications. The fascia was closed only at the umbilicus and 12-mm port site; the fascia at the 8-mm port sites was not closed. The patient was initially discharged without complications; however, on postoperative day 11, the patient was urgently hospitalized again because of PSH incarceration. After manual reduction, the fascia was sutured closed under local anesthesia. The hernial defect was small and barely allowed the insertion of a little finger. There was no evidence of compression or significant damage to the fascia. On postoperative day 27, the patient was discharged after experiencing good recovery.ConclusionsRobotic-assisted colectomy could contribute to the risk of PSHs because of its surgical characteristics. Although routine closure of the fascia at 8-mm port sites is not mandatory, it may be beneficial in certain cases.

Клиническое течение и распространенность ожирения в сочетании с дисфункцией сфинктера Одди по панкреатическому типу у подростков

Актуальность. Гастроэнтерологические проявления ожирения являются актуальной проблемой медицины вследствие взаимоотягощающего характера. Цель работы: изучить распространенность и клинические особенности течения у подростков с алиментарно-конституциональным ожирением и сопутствующей дисфункцией сфинктера Одди по панкреатическому типу и без данного сочетания. Материалы и методы. Обследованы 120 подростков с алиментарно-конституциональным ожирением в сочетании с дисфункцией сфинктера Одди по панкреатическому типу, которые находились на лечении в областной детской клинической больнице г. Ивано-Франковска за период с 2016 по 2019 год включительно. Больные подлежали комплексному обследованию в соответствии с современными протоколами диагностики и лечения. Результаты. Распространенность ожирения по Украине, по данным статистики, составляла 13,4 % на 1000 детского населения. Среди пациентов преобладали мальчики (70,0 и 30,0 %, р < 0,05). Продолжительность болезни у большинства детей с сочетанной патологией составила 6,0 ± 2,1 года, а в случае изолированного течения заболевания — 4,5 ± 3,1 года. К доминирующим факторам риска вовлечения поджелудочной железы в патологический процесс относились: генетическая предрасположенность (наличие ожирения или избыточной массы тела у одного или двух родителей), гиподинамия и нарушение рациона питания (преобладание мучных изделий и сладостей), реже — недостаточный питьевой режим. Среди клинических проявлений сочетанной патологии доминировала спастическая боль с локализацией в левом подреберье и продолжительностью несколько часов, которая плохо снималась спазмолитиками (75,0 и 25,0 %, c2 = 17,69, р < 0,05). Общий диспептический индекс (вздутие живота и понос) у детей с сочетанной патологией был выше, чем у остальных обследованных (5,01 ± 0,06 и 3,02 ± 0,04 балла, р < 0,05). Интоксикационный индекс за счет общей слабости был самым высоким в когорте детей с алиментарно-конституциональным ожирением и функциональным панкреатическим расстройством (7,02 ± 0,06 и 3,50 ± 0,02 балла, р < 0,05). Выводы. Ожирение часто сочетается с функциональной патологией поджелудочной железы, а отдельные клинико-лабораторные маркеры и факторы риска вовлечения поджелудочной железы в патологический процесс должны лечь в основу обновленных протоколов диагностики и лечения.

Faecopneumothorax due to missing diaphragmatic hernia: a case report

BackgroundDiaphragmatic hernias may occur as either congenital or acquired. The most important cause of acquired diaphragmatic hernias is trauma, and the trauma can be due to blunt or penetrating injury. Diaphragmatic hernia may rarely be seen after thoracoabdominal trauma.Case presentationA 54-year-old Turkish male patient admitted to the emergency department with abdominal pain and dyspnea ongoing for 2 days. He had general abdominal tenderness in all quadrants. He had a history of a stabbing incident in his left subcostal region 3 months ago without any pathological findings in thoracoabdominal computed tomography scan. New thoracoabdominal computed tomography showed a diaphragmatic hernia and fluid in the hernia sac. Due to respiratory distress and general abdominal tenderness, the decision to perform an emergency laparotomy was made. There was a 6 cm defect in the diaphragm. There were also necrotic fluids and stool in the hernia sac in the thorax colon resection, and an anastomosis was performed. The defect in the diaphragm was sutured. The oral regimen was started, and when it was tolerated, the regimen was gradually increased. The patient was discharged on the postoperative 11th day.ConclusionsAcquired diaphragmatic hernia may be asymptomatic or may present with complications leading to sepsis. In this report, acquired diaphragmatic hernia and associated colonic perforation of a patient with a history of stab wounds was presented.

Multilocular Cystic Nephroma: A Rare Presentation in a Young Female

Multilocular cystic nephroma represents a rare benign cystic lesion of the kidney, which usually presents as a unilateral multicystic renal mass without solid elements. It has a bimodal distribution presenting in children between three months to two years, and over 30 years of age in adults. Only 5% of cases occur in young adults. We report case of a 16-year-old female who came with complaints of dull non-radiating pain in left flank since three months and hematuria since 1 week. On palpation, a mass was felt in left subcostal and lumbar region. Ultrasonography and Computed tomography scan showed multiloculated cystic mass in left kidney. Left side nephrectomy was done and specimen was sent for histopathology. Based on histopathological findings, an impression of multilocular cystic nephroma was given. Multilocular cystic nephroma should be considered in the differential diagnosis of malignant cystic renal tumors in both children and adults. Its nonspecific clinical presentations and confusing radiological features create difficult preoperative differentiation. Better diagnostic methods in future may spare the kidney.

Robotic Removal of a Hypogastric Splenic Cyst. A Case Report and Review of Literature

Background: Splenic cysts are infrequent findings in everyday medical practice. They are usually associated with nonspecific symptoms and the diagnosis is incidental. In most instances they are located in the left subcostal region, except for cases of huge sized cysts which can extend to the whole abdomen or pelvis. Aim: To present a case of a large hypogastric splenic cyst in a nulliparous woman, managed with robotic cystectomy. Review of the literature is included. Case: A 19-year-old woman, presented to the gynecologic department with a painless, palpable mass in the lower abdomen. Ultrasonography revealed a pelvic cystic mass, originally misdiagnosed for an ovarian cyst. Serum biomarkers and β-hCG were negative. Definite diagnosis was made during explorative laparoscopy where the cyst was found to originate from the spleen. The surgery setup was changed from a lower to upper abdominal procedure. A robotically-assisted cystectomy was performed without concurrent splenectomy, and the splenic cavity was filled with an omental patch. There was no blood loss and the operation time was 163 minutes. Recovery was uneventful and there was no recurrence for a period of 16 months postoperatively. Conclusions: Pelvic splenic cysts are rare, and may be incidental findings during routine abdominal ultrasound scans. Modern minimally invasive approaches such as robotic surgery offer safe and efficient alternatives to standard techniques.

Robotic Abdominoperineal Resection for Lower Rectal Cancers: How We Do It?

Abstract Introduction: Robotic approach has been increasingly applied to the surgical resection of distal rectal cancer. All reports from the advocators on the use of robotic assistance in rectal s...

Metabolic Surgery for the Treatment of Type 2 Diabetes Mellitus: Safety and Feasibility of Laparoscopic Sleeve Gastrectomy

Abstract Introduction: Type 2 diabetes mellitus (T2DM) and obesity are often associated and represent a complex health problem with debated medical management. Laparoscopic sleeve gastrectomy has gained a great consensus because of its efficacy, and no significant postoperative morbidity. In this report, we describe this relatively recent technique of bariatric surgery. Description of the Video: 00:05—The pneumoperitoneum is performed by Veress needle in the left subcostal region. The optical trocar is positioned at ∼15 cm from the ensiform apophysis on the median. Three trocars of 12 mm were respectively placed on the left pararectal region, right, and right subcostal region, and another trocar of 5 mm was inserted in the left paraumbilical region under laparoscopic vision. 01:20—Marking is performed on the large gastric curve at 6 cm from the pylorus. From this site, there is the progressive skeletrization of the greater curvature with ultrasonic scalpel, and then the sectioning and coagulation of the v...

Robotic Heller Myotomy for the Treatment of Esophageal Achalasia: Technical Note

Abstract Introduction: Myotomy of the cardia is the surgical procedure of choice for esophageal achalasia. This study shows, with a video of technical note, the safety of a robotic approach to perform Heller myotomy. Description of the Video: 00:34—The patient is placed in a supine, reversed Trendelenburg position with approximately 20° of inclination. A pneumoperitoneum is created by introducing a Veress needle into the left hypochondrium. A 12-mm trocar, for the robotic camera, is positioned in the left paraumbilical region. Two 8-mm robotic ports are inserted, respectively, into the right hypochondrium and the left subcostal region. A 12-mm extra port for accessory surgical instruments controlled by the assistant surgeon is placed at the supraumbilical region. 00:45—The left lobe of the liver is raised to expose the cardial region, and the base of the stomach is grabbed, pulling downward and to the right. 00:58—The upper cardial peritoneum is incised using a coagulation hook, exposing the front part of...

Robotic Liver Resection for Colorectal Cancer Metastases: A Feasible and Safe Procedure

Introduction: This study employs a video on surgical techniques to present the author's experience in the use of the Da Vinci Surgical System in robotic hepatic resections.1 Description of the Video: 00:50—The patient is placed in a supine, reversed Trendelenburg position. A pneumoperitoneum is then created by introducing a Veress needle into the right hypochondrium. A 12-mm trocar, for the robotic camera, is positioned in the right paraumbilical region. The three 8-mm robotic ports are inserted, respectively, into the epigastrium, right hypochondrium, and left subcostal region. A 12-mm extra-port for accessory surgical instruments controlled by the assistant surgeon is placed at the umbilicus. 1:38—The exploration of the hepatic parenchyma reveals a repetitive hepatic lesion, approximately 40 mm in diameter, at segment VII protruding from the Glissonian. 2:40—The right lobe of the liver is mobilized by a section of the right coronary ligament. 3:05—The resection of hepatic segment VII can proceed, using ultrasonic scalpels, along the ischemic demarcation line, beginning at the anterior border of the liver. The exposure of the portion of parenchyma to be resectioned is obtained using polypropylene stitches placed at the left resection margins and used for traction by the instrument's fourth arm. 4:24—Hemostasis of any minor bleeding can be carried out using bipolar cautery, while major bleeds are dealt with using selective stitches of polypropylene 4/0. 6:12—A check is then carried out on the hemostasis and biliostasis. 6:30—Having completed the procedure, the operated section is extracted by means of an endocatch by slightly increasing the widening of the operational trocar access. 6:42—The Jackson drain will be positioned close to the slice of hepatic section. The disconnection of the robotic arms and deflation now take place. Finally, the mini-incisions are sutured. Materials and Methods: A 68-year-old man had previously undergone anterior rectal resection for cancer. During the oncology follow-up, computed tomography scan revealed the onset of a repetitive lesion in segment VII of the liver. A hepatic resection with the aid of the Da Vinci robotic surgical system was performed. The Da Vinci Surgical System is a telerobotic device controlled from a surgeon at remote console, while the surgical team is close to the operating table and follows the procedure through a service screen.2 Results and Conclusion: Estimated intraoperative bleeding was 90 mL, and no blood transfusions were necessary in the perioperative period. The operative time was 150 minutes. There was no postoperative morbidity, and the hospital stay was 3 days. The hystopathological examination of the portion of parenchyma removed (90 × 60 × 45 mm), perfectly contained the nodule measuring 45 × 31 mm with ample-free resection margins. This confirmed the radical solution of the robotic approach adopted. The follow-up was 18 months with disease-free survival. Even if comparative studies are necessary to demonstrate real advantages of the robotic approach with respect to classic laparoscopy, the Da Vinci Surgical System allows a large tridimensional field of view, a steady traction, tremor suppression, flexibility of the instruments, and offers improved dexterity with an internal articulated EndoWrist that permits seven degrees of freedom and therefore execution of precise and safe dissection of tissue and sutures.3,4 The authors state that none of the authors involved in the manuscript preparation has any conflicts of interest toward the manuscript itself, neither financial nor moral conflicts. Besides, none of the authors received support in the form of grants, equipment, and/or pharmaceutical items. Runtime of video: 7 mins

Own experience improving port implantation in laparoscopic adjustable gastric banding.

IntroductionLaparoscopic adjustable gastric banding (LAGB) is a method frequently used for treating obesity. It requires periodic band regulation associated with the need for port puncture. However, there is always a substantial risk of port rotation.AimThis publication presents a solution of the problem for a MiniMizer Extra band.Material and methodsOne thousand one hundred and twenty-four individuals were operated on for obesity in the Department of Gastroenterological, Oncological and General Surgery of the Medical University of Lodz between 2005 and 2009. In 637 patients LAGB was performed. These LAGB patients were divided into three groups. In group I (20 patients) MiniMizer Extra bands were placed without port stabilization. In the second group (292 patients) MiniMizer Extra band placement with port stabilization was commenced. In the third group (325 patients) bands of other manufacturers (AMI, Inamed, Midband, Obtech) were used without port stabilization. The port was implanted into the subcutaneous tissue in the left subcostal region, medial to the left working tool trocar position.ResultsPort rotation was observed on the very first band adjustment in 3 (0.92%) and 11 (55%) patients with a band other than MiniMizer Extra (n = 325) and the first 20 patients with a MiniMizer Extra band. A different technique of port stabilization was applied in a further 292 patients on MiniMizer Extra band placement and no port rotation was noted.ConclusionsWe believe that MiniMizer additional port stabilization is necessary for its frequent rotation. Simultaneously, application of our method is easy, does not prolong the procedure significantly and secures comfortable access to the port.

Sternalis Muscle

The sternalis muscle is an anatomic variation well known to anatomists, but relatively unknown to clinicians and surgeons. It is localized superficially to the pectoralis major and can cause a diagnostic dilemma during breast surgery, mammography, and computed tomography and magnetic resonance imaging scans, as its appearance mimics tumor pathology of the region. We studied the presence of longitudinally placed muscles in the anterior thoracic wall in 45 cadavers (90 hemithoraces). In an 83-year-old white male, a rare case of crossed-type sternalis was detected on the left side. The muscle originated from the sternal head of the right sternocleidomastoid, crossed into the opposite parasternal half, and split into 2 tendons and 2 muscle bellies that inserted into the left subcostal arch region. This variant was not included in the available sternalis classifications, and an update is suggested. The muscle is of utmost importance and diagnostic value in routine mammogram screening. Moreover, it is of great value for the plastic surgeon, because identification of the variant can aid the differential diagnosis among other regional lesions. Likewise, its superficial location makes it an ideal candidate for utilization as a muscular flap in plastic reconstruction of the head and neck region.

Dynamic Coronary Artery Compression by Pacemaker Lead

A 12 year-old girl with corrected transposition (L-transposition of the great arteries with ventricular inversion) and congenital complete atrioventricular block underwent epicardial pacemaker implantation with a single ventricular lead at 1 week of life. Subsequently, she presented for routine follow-up care in the electrophysiology clinic with no symptomatic concerns. She denied chest pain. Her physical examination was unremarkable, with the pacemaker generator palpable in the left subcostal region. ECG at that time demonstrated ventricular pacing with 100% capture and no evidence of atrioventricular conduction. Her chest x-ray revealed that the pacemaker lead completely encircled the cardiac silhouette and prompted concern for cardiac strangulation (Figure 1). A subsequent computed tomography scan showed a likely restrictive effect on both ventricles caused by the pacemaker lead encircling the heart with concern …

Laparoscopic Spleen-Preserving Distal Pancreatectomy: Description of an Original Posterior Approach

We are describing in this paper the original and innovative technique we used to perform a spleen-preserving distal pancreatectomy. With the patient positioned on her right lateral side, we inserted four laparoscopic ports in the left subcostal region to enable an upper view on the spleen and its rear attachments. With this approach, we opened and dissected this plan located between the left kidney and the rear aspect of the spleen and of the pancreas. These structures, once liberated naturally, felt "en-bloc" out of the way because of the patient's lateral positioning and the gravity, exposing the operative field without any artificial retraction. Beyond this greater exposure, this new approach offers many other advantages, such as the easiness to be performed by only two operators and the preservation of the anterior abdominal cavity, the great omentum, the splenic vessels, and the short gastric vessels left untouched.

Splenosis: a management conundrum in acute abdominal pain

A 38-year-old woman presented with a 4-day history of left upper quadrant pain and nausea, on the background of occasional mild left upper quadrant pain over the previous year. She gave a history of emergency splenectomy 18 years previously following a jet skiing accident, and was otherwise fit and well. On admission she was in pain, lying in the right lateral position with normal vital signs, a blood pressure of 126/60 mmHg, pulse rate of 72 beats per minute and respiratory rate of 16 breaths per minute. Examination confirmed tenderness in the left upper quadrant and left flank, with no signs of peritonism. Microscopic haematuria was noted; however, intravenous urogram was normal. The patient continued to complain of pain and developed peritonism in the left subcostal region. All haematological and biochemical indices remained normal. An abdominal computed tomography (CT) was performed to rule out any unexpected pathology. This revealed extensive intra-abdominal nodules thought to represent splenosis, based on the history of traumatic splenic rupture and subsequent splenectomy. Splenosis is defined as autotransplantation of splenic tissue to unusual sites after splenic trauma. Two large nodules were located close to the splenic vein (Figure 1). There were no features to suggest either haemorrhage in or infarction of these presumed splenunculi, nor other radiological abnormalities to account for her pain. In light of normal blood indices and equivocal CT result, an active observation strategy of repeated examination, haematological and biochemical testing was adopted. On day three post-admission her left upper quadrant pain became refractory to morphine patient-controlled analgesia, and arterial blood gases on this occasion confirmed a metabolic acidosis with a base deficit of 8.4. The decision was taken to proceed to laparotomy looking for devitalized or ischaemic tissue. Except for adhesions and extensive splenic implantation as per CT findings, this was unremarkable. Multiple spenunculi were noted throughout the abdomen, none appeared to have bled or infarcted. Postoperatively the pain did not settle, requiring increasingly large doses of morphine and necessitating high dependency unit admission. A repeat CT scan, however, showed no change from the previous scan. As the pain failed to resolve or be alleviated by any analgesia, the patient was taken for re-laparotomy 48 hours later. A decision was made to resect the largest splenunculi, which coincided with the anatomical site of the pain. One large splenunculus, lying against the diaphragm, was resected from the splenic vein, another from the omentum and two smaller splenunculi from the region of the pancreatic tail (Figure 2). Postoperatively the patient improved dramatically, was mobilizing well by day 5 and was discharged home pain free 8 days after the second laparotomy. Although the large splenunculus was dusky at resection, histology revealed congestion of the red pulp with no other significant abnormalities.

Editorial: Management of umbilical hernia in patients with advanced liver disease

The tendency for patients with severe liver disease to develop an umbilical hernia has been known for some time.1,2 The denominator is hard to determine, but review of patients referred for consideration of liver transplantation shows that approximately 20% have an umbilical hernia.3 Unlike the general population, in which female sex and obesity are risk factors for umbilical hernia, patients with liver disease who form umbilical hernias are more likely to be men with muscle wasting and ascites. Although the sex difference probably reflects the incidence of cirrhosis, men with liver disease are more likely to develop hernia at the umbilicus than the inguinal canal, unlike the general population, in which the opposite is true. The reason for this is not clear because the contributory factors, abdominal distension and abdominal wall weakness, are as likely to promote an inguinal hernia as an umbilical hernia. A personal hypothesis is that portosystemic venous communication at the umbilicus transmits the additional pressure required to favor herniation to the umbilicus rather than the groin. An umbilical hernia often is accompanied by marked thrombocytopenia, even before ascites is evident. If true, it has important implications in planning the repair of an umbilical hernia in cirrhotic patients. Traditional repairs made before transplantation usually fail. Although ascites and muscle wasting are thought to contribute to the development of umbilical hernias, one third of patients will present with an umbilical hernia before the diagnosis of liver disease.2,3 In a review by the author’s group,3 several patients underwent three or four repairs before referral for transplantation. The skin over a large hernia thins and becomes prone to necrosis. Spontaneous leakage of ascites, bleeding from umbilical varices, and bacterial or fungal peritonitis may ensue. Umbilical hernias rarely incarcerate in the presence of ascites. Conversely, successful treatment of ascites may become a prelude to incarceration.3,4 The best time for umbilical hernia repair has not been considered in the literature; however, control of ascites is believed to be essential to success.1,5,6 Taking these factors into consideration, an algorithm for the management of umbilical hernias in patients with severe liver disease is suggested (Fig. 1). Liver transplantation candidates with an uncomplicated umbilical hernia usually postpone repair until transplantation unless there is rapid resolution of ascites. Urgent repair of a complicated hernia requires a strategy to control ascites, if present. Ultra–low-salt diet, diuretics, abdominal drainage, transjugular intrahepatic portosystemic shunt, and peritoneovenous shunt have each been used.1,5,6 The high rate of recurrence of umbilical hernias in cirrhotic patients is from the era of suture repair. A trial of prosthetic mesh repair in the general population shows a lower hernia recurrence rate, but a greater wound complication rate, than suture repair.7 The latter problem may be addressed using the laparoscopic approach.8 In this issue of Liver Transplantation, Sarit, Eliezer, and Mizrahi describe laparoscopic reduction of an incarcerated bowel and placement of a mesh prosthesis to repair a recurrent hernia in a patient with cirrhosis.9 Certain risks specific to cirrhotic patients inherent in this surgical approach were not encountered. Trocar placement in the left subcostal region must be careful to avoid an enlarged spleen. Reduction of incarcerated hernia contents may be hampered by the proximity and adherence of umbilical varices. This also will make it hazardous to dissect the hernia sac and create a preperitoneal space for the mesh. Intraperitoneal placement of mesh will be prone to displacement by ascites or the formation of adhesions to intestine. Multiple trocar sites increase the potential for an ascitic leak. The surgical strategy should account for these risks. A preoperative duplex ultrasound examination will confirm the position of the spleen, determine if there is flow in the umbilical vein, and, possibly, outline the

Leiomyosarcoma of the spleen

Surgery 2001;130:893-4.

The lateral approach to laparoscopic splenectomy

Background Laparoscopic splenectomy has been shown to result in shorter hospital stays and a quicker return to work than conventional splenectomy. Having tried the anterior 5 trocar approach, we developed a 4 trocar lateral approach and now present our experience with 22 cases. Methods All patients were placed in the right lateral decubitus position. A 10-mm trocar was inserted in the left subcostal region, 2 in the flank, and a 5-mm trocar dorsally. A 30° laparoscope was used. Splenectomy was performed for varying pathologies. Results Operating room (OR) time averaged 169 minutes, spleen weight 513 grams, and postoperative (post-op) stays 5.4 days (median 3 days). One patient was converted to laparotomy. There were no deaths, post-op abscesses, pancreatic injuries, or bleeding complications. Conclusions The lateral approach affords superior exposure, allowing easier dissection of splenic hilar structures. Over varying patient habitus and spleen size it has been demonstrated to be the approach of choice for laparoscopic splenectomy.

A CASE REPORT OF GIANT LEIOMYOSARCOMA DEVELOPED IN RETROPERITONEAL SPACE

We report a case of giant leiomyosarcoma developed in the retroperitoneal space. Patient is a 68 y/o male and he came to our hospital with the chief complaint of left upper quadrant mass. A child's head size of elastic hard mass was palpated in the left subcostal region. Under the diagnosis of the retroperitoneal tumor by the abdominal ultrasonography, CT scan, and angiography, the operation was carried out. The tumor, 2180gr., developed in the retroperitoneum was resected with the spleen and the pancreas body and tail. The metastasis to the other organ and lymphnodes was not recognized and pathological diagnosis was leiomyosarcoma. Postoperative course was uneventful, and the patient was discharged 2 months later from the operation. The retroperitoneal leiomyosarcoma is relatively rare disease, and about 90 cases have been reported. The prognosis is poor, because the symptoms appear so slowly that the patient does not come to the hospital until the mass can be palpated.

A CASE OF PRIMARY SPLENIC MALIGNANT LYMPHOMA AND A REVIEW OF 98 CASES REPORTED IN JAPAN

A 56-year-old male who had chief complaints of abdominal distention and general fatigue during therapy for liver cirrhosis was diagnosed as having primary splenic malignant lymphoma by echography, computed tomography, angiography and other examination procedures. He was treated by splenectomy and chemotherapy. The lesion, localized in the spleen which was 18×10×6 cm in size, had a tumor in its lower pole. The cut surface of the tumor was nodular and whitish-yellow and was demarcated clearly within the intact spleen. The pathological finding of this tumor was immunoblastic, plasmacytoid, B cell-type malignant lymphoma according to A Working Formulation of Non-Hodgkin's Lymphomas for Clinical Usage.Ninety-eight cases of primary splenic malignant lymphoma have been reported in Japan. The ages of the patients ranged from 14 to 75 years (average 48.8 years), and the male-to-female ratio was 2.2:1. Most patients had chief complaints of pain and palpable tumor in the left subcostal region. They developed severe splenomegaly 4-45 cm (average 13.4 cm) in size and 280-4500 g (average 1440 g) in weight. Most of them were treated by splenectomy, but their prognosis was mostly poor.It should be emphasized that primary splenic lymphomas can be diagnosed with certainty preoperatively by imaging methods, and that they should be classified pathologically according to A Working Formulation of Non-Hodgkin's Lymphomas for Clinical Usage, considering their therapy and prognosis.