History Of Previous Laparotomy Research Articles

Abdominal wall endometriosis: Case-series study and a systematic review

Abdominal wall endometriosis (AWE) is the presence of endometrial gland and stroma in the abdominal wall that should be kept in mind in differential diagnosis of pelvic pain due to especially increased C-section rates. Between January 2000 and July 2018, MEDLINE and EMBASE databases were systematically reviewed using the search criteria "abdominal wall endometriosis," "abdominal wall endometriomas,”. Only the studies having over 20 patients were included. Case-series, case-control studies, and articles in languages other than English were excluded. Number of the patients, patients ‘age, study design, previous surgical history, most common symptom, time interval to symptoms, treatment, recurrence rate, and tumour size were investigated. In Total, 18 studies and 994 women were included in the study. Case studies, studies with less than 20 cases, non-English articles were excluded from the study. In the included studies, the numbers of minimum and maximum woman were 20 and 227, respectively. AWE significantly impairs the quality of life in reproductive age patients and is commonly seen in women with previous history of laparotomy, especially those who underwent cesarean section. Therefore, it must be kept in mind in the differential diagnosis of women who have a history of pain and a history of previous surgery.

A hospital-based assessment of the efficacy of prophylactic antibiotic usage to that of regular antibiotics usage in patients undergoing elective caesarean section: A comparative study

Aim: This study was planned to assess the efficacy of prophylactic antibiotic usage to that of regular antibiotics usage in patients undergoing elective surgeries. Material and Methods: A comparative Prospective study was conducted in the Department of obstetrics and gynaecology, Mamata Academy of Medical Sciences, Bachupally, Hyderabad, India for the period of 2 years. Total 200 Patients for elective LSCS and BMI < 30 were include in this study. Group A - patients received injection Ceftriaxone 1gm. intravenous stat at the time of induction of anesthesia. Group B - patients received intravenous ampicillin and metronidazole for 1 day followed by oral for next 5 days. Temperature monitoring, vital signs, abdominal, perineal examinations were performed daily till 5-7 days. Results: Patients were randomly divided on alternate number basis, in 2 groups (Group A Ceftriaxone 1gm iv stat and Group B ampicillin and metronidazole for 5 days) each consisted of 100 patients. Mean age was 24.5±4.2 years in group A & 23.4±3.8 years in group B. BMI at the time of admission was 27.9±7.8 kg/m² & 28.8± 6.2 kg/m² in group A & B respectively. Mean duration of surgery was 45.8±6.8 min in group A & 46.1±5.4 in group B. Average blood loss was in groups A 645±70 & 670±75 in group B was comparable. Mean days of hospitalisation was 4.6±4.1 days & 5.4±3.1 days in group A & B respectively. History of previous laparotomy like LSCS, ectopic surgery, etc. was present in 42 & 36 patients from group A & B respectively. Fever was most common morbidity noted (Group A – 7& Group B -5) followed by urinary tract infection (Group A – 5 & Group B -7), wound infection, endometritis & early neonatal sepsis. Statistical difference between group A & B was non-significant for all morbidities. Conclusion: We conclude that the single dose antibiotic prophylaxis is as effective as conventional multi dose antibiotic therapy.

Coexistence of Stump Appendicitis and Ovarian Fibro-Thecoma in a Young Women with Recurrent Right Iliac Fossa Pain During Pregnancy; A Rare Case Report

Ovarian Fibro-thecoma is a rare, benign, sex cord-stromal neoplasm, with a typically unilateral location in the ovary, characterized by mixed features of both fibroma and thecoma. Ovarian Fibro-thecoma is Uncommon tumor of gonadal stromal cell origin accounting for 3-4% of all ovarian tumors. We describe a rare case of Fibro-thecoma in a 27- year women with a history of recurrent right iliac fossa pain during pregnancy associated with fever and vomiting with previous history of laparotomy for appendicular abscess 10 years back. She presented to us during pregnancy with this complain for which she was managed conservatively. She did not maintain her follow up regularly at our hospital and visited again after delivery of her baby with a still birth outcome with a newly diagnosed complex bilateral ovarian cyst demonstrated on ultrasound and computed tomography showed inflammatory Right sided tubo-ovarian mass along with inflammatory thickening of ileum in right lower quadrant adjacent to right ovarian mass lesion. The patient underwent laparotomy for this with the removal of mass along with the removal of appendicular stump for appendicular stump appendicitis which was diagnosed intraoperatively. The finding from histopathological examination of the mass was consistent with the diagnosis of Fibro-thecoma.

PREDICTIVE FACTORS OF INCISIONAL HERNIA AFTER NEPHRECTOMY

Abstract INTRODUCTION Kidney diseases’ surgical approach is multiple, tending to reduce postoperative complications such as incisional hernia, a complication with an incidence around 5-15% and which usually appears after the first year of surgery, being this the possible trigger of serious pathologies that make essential the need to identify predictive factors of its appearance. MATERIAL AND METHODS A retrospective observational study was carried out in 269 patients undergoing nephrectomy (partial or radical) or nephroureterectomy between 2004 and 2018, with the aim of identifying possible predictive factors of incisional hernia after these surgeries. Preoperative (epidemiological and comorbidities), intraoperative (type of surgery, approach and closure, duration) and postoperative data (different possible complications) were taken into account. A univariate and multivariate analysis were performed, using Chi-square test and logistic regression, respectively. RESULTS The median follow-up time was 52.2 months (SD = 39.5), time in which 22 patients had an incisional hernia (8.2%), showing this association with preoperative and postoperative variables. As preoperative data COPD, obesity, ASA and a history of previous laparotomy were related in the univariate analysis, while only obesity was associated in the multivariate analysis (p = 0.003); among postoperative items surgical wound infection, postoperative pulmonary complication, seroma and the need for transfusion and reoperation showed association in the univariate analysis, but only surgical wound infection was the one confirmed in the multivariate analysis (p = 0.049). CONCLUSIONS Obesity and surgical wound infection were proved to be the main predictive factors for the appearance of incisional hernia after nephrectomy.

Effectiveness of Prophylactic Intraperitoneal Mesh Implantation for Prevention of Incisional Hernia in Patients Undergoing Open Abdominal Surgery

Incisional hernia is a frequent complication after open abdominal surgery. Prophylactic mesh implantation in the onlay or sublay position requires dissection of the abdominal wall, potentially leading to wound-associated complications. To compare the incidence of incisional hernia among patients after prophylactic intraperitoneal mesh implantation with that among patients after standard abdominal closure. An open-label randomized clinical trial was performed in 169 patients undergoing elective open abdominal surgery from January 1, 2011, to February 29, 2014. Follow-up examinations were performed 1 year and 3 years after surgery. The study was conducted at Bern University Hospital, Bern, Switzerland, a referral center that offers the whole spectrum of abdominal surgical interventions. Patients with 2 or more of the following risk factors were included: overweight or obesity, diagnosis of neoplastic disease, male sex, or history of previous laparotomy. Patients were randomly assigned to prophylactic intraperitoneal mesh implantation or standard abdominal closure. Data were analyzed in August 2017. Intraperitoneal implantation of a polypropylene-polyvinylidene fluoride mesh with circumferential fixation. The primary end point was the incidence of incisional hernia 3 years after surgery. Secondary end points included mesh-related complications. After the exclusion of 19 patients, 150 patients (81 in the control group and 69 in the mesh group; mean [SD] age, 64.2 [11.1] years; 102 [68.0%] male) were studied. The cumulative incidence of incisional hernia was significantly lower in the mesh group compared with the control group (5 of 69 [7.2%] vs 15 of 81 [18.5%], log-rank test P = .03). Abdominal pain was observed in significantly more patients in the mesh group compared with the control group at 6 weeks (34 of 52 [65%] vs 26 of 59 [44%], P = .04) but not at 12 and 36 months postoperatively. No difference in surgical site infections was observed, but time to complete wound healing of surgical site infection was significantly longer in patients with mesh implantation (median [interquartile range], 8 [6-24] weeks compared with 5 [1-9] weeks; P = .03). Trunk extension was significantly decreased after mesh implantation compared with the control group (mean [SD], 1.73 [0.97] cm vs 2.40 [1.23] cm, P = .009). In patients at elevated risk for incisional hernia, prophylactic intraperitoneal mesh implantation reduces the incidence of hernia formation but with increased early postoperative pain and prolonged wound healing of surgical site infection. ClinicalTrials.gov Identifier: NCT01203553.

English

INTRODUCTION: Post operative adhesions form one of the most common complication following abdominopelvic surgeries. the consequence of adhesion leads to lifelong morbidity and form major burden in surgeons operating for the second time. Few complications of adhesions include postoperative adhesive colic, bowel obstruction and female infertility Frequent readmissions leads to mobility of patients. Difficulty in resurgery on opening the abdomen for the second time comprises an important outcome of adhesions.Adhesiolysis stays atemporary mainstay treatment to remove adhesions as they tend to reccur following subsequent surgeries. There is need for thorough understanding of the formation adhesions, which is mainly due to reaction of the peritoneum with the intestinal loops which comes in contact with it, the complication of peritonitis, the pathology of bowel obstruction and the evolution of the adhesion barrier. RESEARCH PROPOSAL: a) AIM AND OBJECTIVES OF THE STUDY: Effectiveness of Seprafilm as adhesion barrier among patients undergoing elective laparotomy. e) METHOD OF COLLECTION OF DATA: a. Patients under the study group will be subjected to placement of seprafilm. b. Contrast Enhanced Computerised Tomogram will be performed for all the patients (both study and control) during 20th post operative day DISCUSSION: Results In our study distribution of age is categorised into age<40,41-50 and 51-60.The Mean age in cases is 46.2 and in control group was 46.36.The p value is 0.963 which is not significant. Thus in our study age does not contribute in formation of adhesions for the placement of Sepra In this study male:female ratio in the study group is 11:19 and in the control group is 12:18.The p value is 0.946 which is not significant. Thus male and female have equal preponderance in formation of postoperative adhesions thus In this study 17 cases in the study group and 15 cases in the control group had previous history of surgery. There is no specific difference in the changes in adhesions in previous history of laparotomy done. favouring application of seprafilm in both sex 3 patients developed postoperative fever which settled before 3rd postoperative day.1 case developed wound infection which was managed conservatively. In the control group 9 cases developed fever which settled within 3rd post operative day.4 patients developed postoperative pain till 7th day which may attribute to formation of adhesions as all developed adhesions in the 20th day CT. CONCLUSION: Out of 30 patients only 4 patients developed mimimal adhesions as compared to 16 patients who developed adhesions in the control group as evident by the 20th 90 day CT. The pvalue 0.037 which is significant thus proving the effectiveness of seprafilm as an adhesion barrier in abdominopelvic surgery.

The Benefits of a Wound Protector in Preventing Incisional Surgical Site Infection in Elective Open Digestive Surgery: A Large-Scale Cohort Study.

The objective of this study was to evaluate the benefits of wound protectors (WPs) in preventing incisional surgical site infection (I-SSI) in open elective digestive surgery using data from a large-scale, multi-institutional cohort study. Patients who had elective digestive surgery for malignant neoplasms between November 2009 and February 2011 were included. The protective value of WPs against I-SSI was evaluated. A total of 3201 patients were analyzed. A WP was used in 1022 patients (32%). The incident rate of I-SSI (not including organ/space SSI) was 9%. In the univariate and the multivariate analyses for perioperative risk factors for I-SSI, the use of WP was an independent favorable factor that reduced the incidence of I-SSI (odds ratio 0.73, 95% confidence interval 0.55-0.98. P=0.038). The subgroup forest plot analyses revealed that WP reduced the risk of I-SSI only in patients aged 74years or younger, males, non-obese patients (body mass index <25kg/m2), patients with an American Society of Anesthesiologists score of 1/2, patients with a previous history of laparotomy, non-smokers, and patients who underwent colon and rectum operations. In patients who underwent colorectal surgery, the postoperative hospital stay was significantly shorter in patients with WP than those without WP (median 13 vs. 15days, P=0.040). In terms of the depth of SSI, WP only prevented superficial I-SSI and did not reduce the incidence of deep I-SSI. WP is a useful device for preventing superficial I-SSI in open elective digestive surgery. UMIN000004723.

Abdominal Gossypiboma: A Diagnostic Dilemma in Late Postoperative Period

Abstract: We reported a case of gossypiboma in 59-year old woman who presented with vague abdominal pain since her cesarean section and described her plain radiograph and abdominal CT scan. Keywords: Gossypiboma Introduction: 59-year old woman was admitted in our emergency department because of long lasting vague abdominal pain. She had occasionally nausea and vomiting however with no weight loss. Her past medical history was unremarkable except for cesarean section performed 15 years ago. On physical examination mild periumbilical tenderness was found and routine lab data showed no abnormality. Plain abdominal radiograph was performed which showed linear metallic density in the midpart of abdomen (Figure 1). Abdominal CT scan showed a well-defined mass like structure in RT sided abdominal cavity with no peripheral fat stranding with metallic artifact within it (Figure 2). Diagnosis of gossypiboma was made preoperatively. Surgery was done which revealed surgical sponge within abdominal cavity. The patient’s symptom resolved after surgery. Gossypiboma is a term used for description of any surgical substance remained within the body with retained surgical cotton or sponge as the commonest reported intra-abdominal foreign body. For many years they can be unnoticed until they lead to complications [1]. Gossypiboma is an avoidable condition should be considered in any postoperative patient who presents with unusual manifestation as it can be misdiagnosed and unnecessary procedure may be done [2]. In spite of its rarity in clinical practice in any patient with previous history of laparotomy should be considered as one of differential diagnosis [3]. It can cause significant morbidity or even mortality for patients and most patients with gossypiboma of abdomen are symptomatic and present with nonspecific abdominal pain [4]. Retained surgical sponge or gossypiboma is a serious unusual condition with medicolegal effect that its frequency is difficult to estimate however seems to be 1 in 1000 to 1500 intra-abdominal operations. The gossypiboma even if aseptic can induce foreign body reaction and mimic a soft tissue neoplasm and usually misinterpreted preoperatively due to low clinical and even radiological suspicious [5]. It can be anywhere in the body with intra-abdominal location as the most common site but unusual location such as paraspinal muscle, shoulder and intrathoracic region also have been reported. They usually diagnosed with radiological examination as radio-opaque density within surgical sponge help diagnosis easily however radiolucent density cause dilemma for correct diagnosis. CT scan may be needed especially in chronic presentation as they can present like a soft tissue neoplasm which revealed hypodense structure with peripheral thick rim [6]. Various imaging appearances present depending on time of retention and surgical site. They can be seen as sponge-like appearance due to bacterial overgrowth within surgical sponge and whirl like structure. In MRI, in T2 weighted sequence, folded fabric structure demonstrated. Negative uptake in scintigraphy study help in differentiation of same appearance soft tissue tumors from gossypiboma in equivocal cases [7,8]. Other radiologic characteristics in acute post-operative phase may mimic hematoma, abscess or seroma formation but in chronic phase they may be confused with chronic granulomatous reaction or soft tissue tumors[7]. Sarcoma may arise from gossypiboma in rare frequency when retention time is more than 20 years so it is necessary for careful examination of gossypiboma resected specimen for rule out of coexisting sarcoma [8]. It is preventable event with staff change avoidance during surgery and strict swab count. Minimally invasive procedures also help in decreasing its incidence [9]. Conclusion: Gossypiboma is an avoidable condition that should be considered in differential diagnosis of any patient with previous history of operation with unusual presentation in acute or chronic states.

Laparoscopic cholecystectomy: Conversion rate and complcation

Introduction and Objective: Laparoscopic Cholecystectomy is the standard surgical treatment for gallbladder disease. However, conversion to open surgery is not the complication. Different centers have reported different conversion rates and post operative complications. The objective of this study is to identify conversion rate and post operative complication of laparoscopic cholecystectomyMaterials and Methods: This retrospective study included all laparoscopic cholecystectomies attempted in Dhulikhel hospital during the year 2015. Files of all patients were reviewed to find out the demography of the patients and the indication of Laparoscopic cholecystectomy. The rate of conversion to open cholecystectomy, the underlying reasons for conversion and postoperative complications were analyzed.Results: Out of 324 cases attempted laparoscopic cholecystetomies, two cases with the history of previous laparotomy were excluded to rule out the bias in the result. Out of 322 cases 226(70.18%)were female and 96(29.81%) were male . The mean age was 38 years. Over all conversion rate to open cholecystetomy was 1.86% with frozen calot’s triangle as the most common reason for conversion. The over all postoperative complication was 1.24% with no major bile duct injury.Conclusion: Laparoscopic cholecystectomy can safely be done with low conversion rate and complication.

Laparoscopy versus laparotomy for the management of endometrial carcinoma in morbidly obese patients: a prospective study

To compare the results of total laparoscopic hysterectomy and total abdominal hysterectomy in morbidly obese women with early stage endometrial cancer. This prospective study was conducted on 140 morbidly obese women with body mass indices ≥35 kg/m(2) and presenting with clinical stage 1 endometrial cancer. The patients underwent total laparoscopic hysterectomy (n=70) or total abdominal hysterectomy (n=70), bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and peritoneal washing. Age, parity, menopausal status, weight, height, medical problems, history of previous laparotomy, surgical procedure, operative time, estimated amount of blood loss, preoperative hematocrit, postoperative hematocrit, operative complications, conversion to laparotomy, need for intraoperative or postoperative blood transfusion, intraoperative and postoperative complications, secondary surgery, tumor stage, grade, histology, number of recovered lymph nodes, and visual pain scores of the patients were recorded. Postoperative complications were significantly higher in the laparotomy group. Hospital stay in the laparoscopy group was significantly lower than that in the laparotomy group. The visual pain scores were significantly higher in the laparotomy group on the first, second, and third postoperative days and on the day of discharge from the hospital. Resuming activity took a significantly longer time in the laparotomy group (34.70 days) than in the laparoscopic group (17.89 days). With the availability of skilled endoscopic surgeons, most obese women with early stage endometrial cancer can be safely managed by performing laparoscopy with an excellent surgical outcome, shorter hospitalization, less postoperative pain, and faster resumption of full activity.

A 16-Year-Old Female with Peutz-Jeghers Syndrome

Peutz-Jeghers syndrome is a rare autosomal dominant disorder of hamartomatous polyposis of the gastrointestinal tract, with pigmentation around lips and macules on the buccal mucosa that typically manifests itself as recurrent colicky abdominal pain and intestinal obstruction due to intussusception. Here we report a case of a 16-year-old girl who presented with abdominal pain, vomiting and previous history of laparotomy for intussusception. Multiple well demarcated black pigmented macules on lips, perioral region, buccal mucosa, digits, palms and soles were noted. She was diagnosed as a case of Peutz-Jeghers syndrome and managed conservatively. DOI: http://dx.doi.org/10.3329/jemc.v4i3.20958 J Enam Med Col 2014; 4(3): 184-187

Distal intestinal obstruction syndrome in cystic fibrosis: presentation, outcome and management in a tertiary hospital (2007–2012)

Cystic fibrosis (CF) can result in distal intestinal obstruction syndrome (DIOS) due to inspissated mucus. This paper describes the clinicopathological characteristics of adult CF patients with DIOS and assesses risk factors for surgery. A retrospective audit of CF patients at the Alfred Hospital from January 2007 to February 2012 was carried out. Patients who had 'bowel obstruction or constipation' were abstracted from the database, and medical records were reviewed for a diagnosis of DIOS. Forty-five encounters of 35 patients were extracted. Twenty-five (83%) patients were homozygous for the delta F508 mutations, 29 (85%) had pancreatic insufficiency and 15 (44%) had a lung transplant. Patients presented with abdominal pain (96% of encounters), nausea (76% of encounters) and vomiting (67% of encounters). Computed tomography (CT) was performed in 20 episodes. Compared with CT, abdominal X-ray had a sensitivity of 63% (95% confidence interval (CI) 30-89%) and specificity of 33% (95% CI 8-70%) for detecting DIOS with obstruction. Forty-one (91%) encounters resolved with medical management within 2-3 days. Three patients required surgical intervention in four episodes. Previous laparotomy (odds ratio (OR) 28.5, 95% CI 1.3-624, P=0.03) and history of meconium ileus (OR 14, 95% CI 1-192, P<0.05) were statistically significant predictors of progression to surgical management. In most patients with DIOS, the obstruction resolves with medical management. Early consultation with a CF service, assessment for a surgical abdomen and involvement of surgeons where appropriate is recommended. A history of previous laparotomy is a risk factor for the need for surgical intervention.

Cystadenoma of the appendix presenting with an intestinal obstruction of the ileum: A case report

Introduction: Small bowel obstruction due to an appendiceal mucocele is comparatively rare. Case Report: A rare case of a small bowel obstruction due to a mucocele of the appendix, which had been histopathologically diagnosed as a mucinous cystadenoma. Partial resection of the ileum and appendectomy through traditional laparotomy relieved the patient from abdominal pain and congestion from the intestinal obstruction. Conclusion: Small bowel obstruction due to an appendiceal mucocele should be considered among the differential diagnosis of intestinal obstruction for patients who have no previous history of laparotomy.

Adhesive bowel obstruction? Not always

A 58-year-old man presented acutely with features of post-surgical adhesive small bowel obstruction. Following an unsuccessful trial of conservative management, computed tomography (CT) of the abdomen was performed. This revealed a mass in the ileocaecal region, for which he underwent a subsequent right hemicolectomy. Histology revealed diffuse B-cell Non-Hodgkin’s lymphoma of the terminal ileum. Confounding obstructive lesion of the intestine in patients with a history of previous laparotomy is extremely uncommon. Early high resolution imaging may predict diagnosis and consolidate clinical management plans.

Modular Training in Laparoscopic Colorectal Surgery Maximizes Training Opportunities without Clinical Compromise

Laparoscopic surgery is increasingly proposed as the gold standard technique for colorectal resections and is offered to greater numbers of patients. To meet the rising service demands, more trainees and established consultants need to learn the technique. We sought to establish whether it is feasible and safe to train on a large proportion of patients without adversely affecting clinical outcome or smooth running of clinical service. Between September 2006 and July 2008, four senior trainees of the Wessex Specialist Registrar training rotation were involved in training in laparoscopic colorectal surgery. Major colorectal resections were separated into clearly defined modules for training purposes. Right and left hemicolectomies each comprised two modules, and low anterior resection comprised three modules. Prospective data on consecutive patients undergoing laparoscopic colorectal surgery were collected. Data included type of surgery, module of procedure performed by trainee or trainer, body mass index (BMI), conversion rates, median operative time, complications, length of hospital stay, and mortality. During the study period 227 colorectal resections were attempted laparoscopically. Of these, 216 (96%) proved suitable for training and 97% were completed laparoscopically. Some 23% of patients were American Society of Anesthesiologists score (ASA)≥3; 35% had a BMI≥28; 38% had a history of previous laparotomy. Trainees performed 96% (142/148) of right hemicolectomy modules, 99% (154/156) of left hemicolectomy modules, and 67% (128/192) of rectal resection modules. Each trainee was competent to do right and left hemicolectomy at the end of the training period. Four patients (2%) required further surgery for postoperative complications. Of the procedures completed by the trainees, 155/171 (91%) cancer resections were potentially surgically curative, and R0 resections were achieved in 99%. The readmission rate was 10% (22/216) and median length of hospital stay was 4 days. Postoperative mortality was zero. Using a modular approach it is possible to provide effective training during almost all laparoscopic colorectal resections while achieving good clinical outcomes for the patients.

156: A Novel Method of 9th Intercostal-Microlaparoscopic Approach for Patients with Previous Laparotomy

To evaluate the availability of a primary laparoscopic approach for a patient with previous laparotomy and to assess postoperative adhesion to the abdominal wall. Retrospective study. University hospital. A total of 172 patients with a history of previous laparotomy who were undergoing laparoscopic surgery in our hospital were evaluated. The primary trocar insertion was performed via the 9th intercostal-microlaparoscopic approach for all patients who had undergone laparotomy previously. This procedure could be performed on all 172 patients and there were no complications. Postoperative abdominal wall adhesion was found in 53 (30.8%) of 172 patients with previous laparotomy, and periumbilicus adhesion was found in 16 patients (9.3%). Among the 172 patients, 150, 19, and 3 patients had undergone laparotomy once, twice, and three times, respectively, prior to this study. Considering the number of previous laparotomies, the frequency of abdominal wall adhesion was 23.3% (35/150 patients), 68.4% (13/19 patients), and 66.7% (2/3 patients), and the frequency of periumbilicus adhesion was 5.3% (8/150 patients), 36.8% (7/19 patients), and 33.3% (1/3 patients) in the patients who had undergone laparotomy once, twice, and thrice, respectively. The type of laparotomy among 150 patients who had undergone laparotomy once was an obstetric-and-gynecologic surgery in 126 patients (126/150) and other surgeries in 24 patients (24/150). There was no significant difference in the frequency of adhesion between types of previous laparotomy. Among the 150 patients who had undergone laparotomy once, surgical incisions were classified as median infra-umbilical incision (94/150 patients), median supra-umbilical incision (3/150 patients), Pfannenstiel incision (33/150 patients), para-rectal incision (15/150 patients), and peri-rectal incision (5/150 patients). A high frequency of adhesion to abdominal wall and periumbilicus was recognized in the all three median supra-umbilical incisions. Ninth intercostal-microlaparoscopic approach is a safe for laparoscopic surgery in patients who have undergone laparotomy previously and this procedure could be prevented the risk of bowel injury.

A CASE OF JEJUNUM-INCARCERATED HIATUS HERNIA OF THE ESOPHAGUS ASSOCIATED WITH OMENTAL HIATUS HERNIA

Omental hiatus hernia is a relatively rare entity of all intraabdominal hernias. This time we experienced an extremely rare case of the disease associated with hiatus herina of the esophagus. An 82-year-old woman was seen at the hospital because of upper abdominal pain, and was admitted with a diagnosis of intestinal obstruction. A fluoroscopic study through a long intestinal tube revealed the incarcerated jejunum in a hiatus hernia of the esophagus. The patient was operated on. Upon laparotomy, the jejunum which prolapsed from an omental hiatus hernia along with the fundus of the stomach were incarcerated in the hiatus hernia of the esophagus. No intestinal necrosis was noted, and so a closure of the omental hernia, plication sutures for the esophageal hernia, and posterior fixation of the gastric fundus were performed. In treating intestinal obstruction in elderly patients without previous history of laparotomy, if malignant diseases can be ruled out and conservative treatments are ineffective, laparotomy is a consideration by entertaining a possibility of internal hernia.

Causes of increasing width of right anterior extrarenal space seen in ultrasonographic examinations

The right anterior extrarenal space is composed of the perirenal fascia, the right anterior perirenal space, the right anterior pararenal space, and the liver capsule. To clarify the probable causes of an increasing width of the right anterior extrarenal space, the width was measured using ultrasonography for a period of 8 months. The right anterior extrarenal space was measured 3 cm from the superior renal pole and the smallest width obtained in several different scan planes was used. In 1,114 ultrasound examinations, 35 patients were found to have an increased width of the right anterior extrarenal space. Among the 35 cases, the common probable causes for such a condition were found in 27 cases. Eight patients had hyperchogenicity in the right pararenal space, a condition considered to be due to an acute inflammation, including acute pancreatitis, acute cecal diverticulitis, acute appendicitis, ischemic bowel, acute cholangitis, liver abscess, and penetrated duodenal ulcer. Chronic inflammations of an adjacent organ, a previous history of laparotomy, a malignancy with peritoneal metastases, and treatment with corticosteroid were considered the causes behind the condition in the 19 patients with normal echogenicity. For the remaining 8 patients, causes were not found during the follow-up period. This study indicates that life-threatening diseases, such as acute or chronic inflammatory diseases and malignancy of the abdomen, could be the cause of an increase in the width of this space.

THREE CASES OF INTUSSUSCEPTION ASSOCIATED WITH MALIGNANT INTESTINAL TUMORS

Three adult cases of intussusception associated with malignant tumors of the small intestine are reported. All of them had no history of previous laparotomy, and were diagnosed as intestinal obstruction on admission. The diangosis of intussusception was made by elective examinations following the bowel decompression therapy. The enterography of the oral side of the obstructive lesion showed a tapering shape of the intestinal lumen, which is a characteristic and specific finding of intussusception, and named as “pencil tip appearance”. Mesenteric arteriography was useful in making the diagnosis of intussusception, but it failed to demonstrate location or qualitative picture of the tumors. Most adult intussusceptions are associated with some causative organic diseases. It is often difficult to make definite diagnosis preoperatively that leads to emergency operation in considerable cases. From these experiences, it was clarified that the preoperative intestinal decompression therapy was effective and elective surgery was able to be performed. When we entertain a large probability of malignant primary lesion in adult intussusception, the significance that preoperative evaluation of the pathology can be achieved for an intestinal obstruction should be emphasized for better and more proper operative strategy.

CT and Ultrasound Findings of Surgically Retained Sponges and Towels

The CT and ultrasound features of retained sponges (gossypibomas) are described in six patients. They are well-circumscribed cystic masses without surrounding edema. The retained sponges or towels were correctly identified in only three cases. In the other three cases retained sponges were organized and lost their original configuration. Gas was seen in one case and calcification in two cases. Gossypibomas should be included in the differential diagnosis in all patients with a well-circumscribed cystic mass in the abdomen and with a history of previous laparotomy.