Subcostal Margin Research Articles

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Editor, We would like to thank Dr Yao and Dr Liu for their interest in and valuable comments concerning our manuscript.1 However, we should clarify some points regarding their opinions about our study. First, according to our original definition, we performed the transversus abdominis plane (TAP) block on the anterolateral abdominal wall between the iliac crest and the subcostal margin at the mid-axillary line.2 In a cadaveric study, Tran et al.3 showed that a TAP block, which was applied at the same anatomical location as in our study, affected the lower thoracic nerves (T10 to T12) and the first lumbar nerve (L1). Thus, ilioinguinal nerve and iliohypogastric nerve, which are derived from the L1 nerve root, were blocked at the level of the L1 nerve root. We agree with Yao and Liu about anatomical variations of the branches of L1. In some cases, penetration of the transversus abdominis muscle by L1 nerves may be closer to the anterior superior iliac spine. However, in our opinion, ours and Yao and Liu's definition of the injection points are very close to each other and there is not much difference. As we showed in our study, high volumes of local anaesthetics, may lead to an adequate spread to the entire TAP area including the anterior superior iliac spine. As a result all nerves in this area should be affected and this may minimise the risk of block failures due to anatomic variations. Second, we preferred not to use a placebo group, as we found it unethical in this context. Also, we did not use a regular analgesic regimen in both groups. We observed a higher need for analgesia than a similar, previously published study.4 Third, we support Yao and Liu's opinion in that the TAP block may be a good alternative to the caudal block, which is a kind of central neuroaxial block and may cause adverse effects. There is a need for further randomised controlled trials comparing TAP with caudal block. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.

Is Palmer’s Point Really Safe?

Prior to an IVF cycle, bilateral salpingectomy was planned. At laparoscopy, Palmer’s point (3 cm below the left subcostal margin in the mid-clavicular line) was used for insertion of the Veress needle.1 Moderate omental adhesions at the level of the umbilicus were seen. Unexpected adhesions were also noted when the port site at Palmer’s point was inspected (Figures 1 and 2). Insertion of the Veress needle at Palmer’s point is considered safe in patients with peri-umbilical adhesions2; however adhesions at Palmer’s point may still be found.

Spliceosome Gene Mutations Are Frequently Found In JAK2 Negative Myelofibrosis and Associated With Worse Clinical Outcomes

Myelofibrosis (MF), a Philadelphia chromosome negative myeloproliferative neoplasm (MPN) requires clonal markers for accurate diagnosis according to the 2008 World Health Organization classification scheme. However, molecular mutations in Janus Kinase 2 (JAK2) are found in only 50% of MF patients (pts). Various somatic mutations identified in other myeloid cancers have also been found in MF with pre-existing JAK2 V617F mutations. We previously reported in 57 pts diagnosed with Triple Negative MF (TN-MF: JAK2 exon12/14 and wild type (WT) MPL) the absence of mutations in genes commonly identified in other myeloid malignancies, specifically TET2, DNMT3A, CBL, IDH1/2, SH3B2 (LNK), N/KRAS and EZH2. Only somatic mutations in ASXL1 were identified in a small cohort of TN-MF (16%). Mutations in components of the RNA splicing machinery have been recently identified in varying frequencies in different myeloid malignancies. We performed RNA-sequencing on 2 samples (JAK2 mutant (MUT) and 1 JAK2 WT) and found that 2 spliceosome genes (U2AF1 and SF3B1) had higher mRNA expression levels in the JAK2 WT (MFC=0.76 and 0.82, respectively) compared to JAK2 MUT patient. We hypothesized that somatic mutations in RNA splicing factor genes occur in TN-MF pts and may be helpful in the biological characterization of this group of pts. Therefore, we isolated DNA from bone marrow (BM) or peripheral blood mononuclear cells from a cohort of MF pts (N=132; JAK2 MUT:75 and JAK2 WT:57) and performed Sanger sequencing for SF3B1 (exons 13-16), U2AF1 (exons 2, 6 and 7), and SRSF2 (exons 1 and 2). Baseline characteristics of pts and clinical data including hematologic parameters, BM results, and presence of splenomegaly by palpation were collected. Pts were stratified based on the Dynamic International Prognostic Scoring System-Plus risk as high=40, Int-2=51, Int-1=11 and low-risk=5 pts. The mean duration of follow-up was 16.5 months in JAK2 MUT and 12.8 months in JAK2 WT. Spliceosome mutations were found in 35/132 (27%) (SRSF2=17%, U2AF1=8% and SF3B1=2%) of pts. Interestingly, the frequency of spliceosome mutations in JAK2 WT was higher (31%; SRSF2=26%, U2AF1= 5%, SF3B1=0) compared to JAK2 MUT (18%; SRSF2=10%, U2AF1=6%, SF3B1=2%) pts. Of note, the 2 pts with SF3B1 mutations (K700E) had ring sideroblast in the BM (occasional and 50%). A large number of WT JAK2 patients (50%) had concomitant SRSF2 and ASXL1 mutations. Both SRSF2 and ASXL1 have been associated with poor prognosis in MF. Indeed, in our JAK2 WT cohort, pts who harbored SRSF2 mutations had a higher mean percentage of BM blasts compared to the ones that were SRSF2 WT (5.6% vs 1.8%; P=.006). Moreover, JAK2 WT pts carrying spliceosome mutations had more severe anemia as shown by lower hemoglobin (8.98 g/dL vs 10.5) and higher leukocyte counts (27.5 x109/L vs 20.5) compared to WT cases. Furthermore, we noticed that they also had higher frequency of RBC (Red Blood Cells) transfusions compared to WT (60% vs 40%) cases. Spleen examination by palpation below the left sub-costal margin showed that JAK2 WT cases carrying spliceosome mutations had larger splenomegaly compared to WT cases [10.1 cm (range 4-26), vs 8.7cm (range 2-20); P=0.05]. In conclusion, molecular alterations in the spliceosome machinery are frequently found in MF pts who are WT for JAK2/MPL and are associated with higher BM blast percentage, more severe anemia, higher leukocyte counts, transfusion dependence and more prominent splenomegaly. The observation of appreciable frequency of spliceosome mutations in JAK2 WT MF pts opens the possibility of using spliceosome inhibitors in the management of this disease group. Disclosures:No relevant conflicts of interest to declare.

Comparative study of percutaneous nephrolithotomy for renal upper calyceal stones with two approaches

Objective To investigate and compare the effects of minimally invasive percutaneous nephrolithotomy for renal upper calyceal stones with approaches through upper edge of the 1 lth rib and lower edge of the 11th fib.Methods Two hundred and sixteen cases of kidney stones in our hospital from July 2008 to July 2010 were reviewed.Of which 66 patients were renal calyceal stones.Thirty-two patients underwent the approach through upper edge of the 11th rib (group A),with 15 males and 17 females,with a mean age of 42 years.Ten cases with stone were located on the left side,right 21 cases,and bilateral 1 case,with calculi average maximum diameter of 1.9 cm.Thirty-four cases underwent the approach through lower edge of the 11th path (B group),with 14 males and 20 females,with a mean age of 44 years.Thirteen cases with stone were located on the left side,right 21 cases,with calculi average maximum diameter of 1.7 cm.The two groups underwent minimally invasive percutaneous nephrolithotomy holmium laser lithotripsy lithotomy.The average puncture time,one-time success rate of puncture and disposable stone-free rate were compared.Results Puncture time of group A was 3.0-14.0 min,with an average of 5.8 min,and group B was 3.0-17.0 min with an average of 6.4 min.The disposable puncture success rate of the two groups was 100％.Disposable stone-free rate was 100％ in group A (32/32),and 88％ in group B (30/34) (P ＜ 0.05).There were no pneumothorax,hemothorax,abdominal viscera injury in two groups.Conclusions The minimally invasive percutaneous nephrolithotomy through the approach of upper edge of the llth fib was better than through the approach of conventional lower edge of 11 subcostal margin,with shorter percutaneous renal access distance,and higher stone-free rate. Key words: Nephrostomy, percutaneous; Renal upper calyceal stones; 11 rib

Pseudomesotheliomatous Adenocarcinoma of Lung: A Diagnostic Dilemma

A 52 years old farmer developed left-sided chest pain 4 months prior to admission that was dull aching, episodic, lasting for 1 to 2 minutes, relieved of its own and increased on deep inspiration. He was found to have left-sided pleural effusion. Pleural fluid analysis revealed straw colored fluid with positive stain for acid fast bacilli at Civil Hospital, Rupnagar. He was enrolled under Revised National Tuberculosis Control Programme (RNTCP) for directly observed antitubercular treatment (DOTS) as a new case. Despite 2 months of treatment, there was no symptomatic improvement and repeat evaluation showed a persistent large pleural effusion. Therapeutic thoracocentesis (2-3 times) was done followed by intercostal chest tube insertion 2 months prior to admission with drainage of approximately 200 to 300 ml of hemorrhagic fluid per day. Over a period of 2 weeks preceding admission, severity of chest pain gradually increased. Six days prior to admission, he developed high grade fever associated with rigors and chills. Breathlessness started 4 days prior to admission, was acute in onset, progressing during this time period to being present at rest and not associated with orthopnea or wheeze. There was no history of cough, expectoration, hemoptysis, swelling of feet, decreased urine output or altered sensorium. There was no significant illness in the past. He was a nonsmoker with no addictions. On initial evaluation, he was conscious and oriented. He had tachycardia (130/min), normal blood pressure (130/70 mm Hg) and tachypnea (40/min) with use of accessory muscles of respiration. Pallor, bilateral pitting pedal edema and small right supraclavicular lymph nodes were noted. Examination of the chest revealed presence of a chest tube, reduced chest wall movements with signs of volume loss on the left side, dull note on percussion with reduced intensity of breath sounds in the left infraclavicular and left mammary areas. The clinical findings were consistent with those of pleural effusion. Per abdomen, the liver was palpable 2 cm below right subcostal margin with no other specific features. Spleen was not palpable, there was no tenderness or free fluid and bowel sounds were present. Rest of the systemic examination was unremarkable.

Laparoscopic Adrenalectomy: Step-By-Step Surgical Skills

Introduction and Objective: To introduce step-by-step skills and to show the learning curve of pure laparoscopic adrenalectomy performed by a single surgeon. Materials and Methods: From October 2008 to September 2011, 74 patients out of 112 who were diagnosed as adrenal mass received pure laparoscopic adrenalectomy. Eight cases were bilateral, and 66 cases were unilateral. After placing the patient in the flank position, a 12-mm camera port is inserted near umbilicus. Two 5-mm working ports are placed at the cross-sections of the midclavicle line, anterior axillary line, and subcostal margin. About 2-mm port for liver retraction is placed just below the xiphoid process if the mass is on the right side. When performing a right adrenalectomy, an avascular triangle formed by the vena cava, liver, and renal vein is identified. The adrenal gland is lifted up using a pair of forceps or suction, and adrenal vein is ligated. Inferior phrenic vascular supply at the liver margin and renal hilum vascular supply at the upper pole margin of kidney are secured in order, and then, the adrenal gland is removed. When performing a left adrenalectomy, the line of Toldt, splenocolic ligament, and splenic flexure are incised. The plain between the descending colon, pancreas, spleen, and perirenal fascia is split and flipped over all the way to the medial side. After identifying the renal vein, the adrenal vein is ligated. Following procedures are the same as on the right side. The camera scope is replaced to 5 mm and inserted into 5-mm working port, and a 12-mm port is used for delivering specimen. Drain is not inserted. Results and Conclusions: There was significant improvement in the average operation time (90 vs. 53 minutes, p=0.003) of the latter 33 unilateral laparoscopic adrenalectomies compared to the prior 33 cases. The estimated blood loss (130 vs., 50 mL, p<0.001) also deceased, but had no clinical significance, since it did not exceed 350 mL in both groups. With the knowledge of anatomical structures near the adrenal glands, the surgical techniques introduced here in this video clip will help the surgeon with little experience with adrenalectomy to overcome the learning curve. No competing financial interests exist. Runtime of video: 5 mins 12 secs

V867 LAPAROSCOPIC ADRENALECTOMY STEP-BY-STEP SURGICAL SKILLS

You have accessJournal of UrologyOncology (TCC & Adrenal) & Teaching Techniques1 Apr 2012V867 LAPAROSCOPIC ADRENALECTOMY STEP-BY-STEP SURGICAL SKILLS Hyung Joon Kim, Hyun Hwan Sung, Bumsoo Park, Bong Hee Park, Seong Il Seo, Seong Soo Jeon, Hyun Moo Lee, and Byong Chang Jeong Hyung Joon KimHyung Joon Kim Seoul, Korea, Republic of Korea More articles by this author , Hyun Hwan SungHyun Hwan Sung Seoul, Korea, Republic of Korea More articles by this author , Bumsoo ParkBumsoo Park Seoul, Korea, Republic of Korea More articles by this author , Bong Hee ParkBong Hee Park Seoul, Korea, Republic of Korea More articles by this author , Seong Il SeoSeong Il Seo Seoul, Korea, Republic of Korea More articles by this author , Seong Soo JeonSeong Soo Jeon Seoul, Korea, Republic of Korea More articles by this author , Hyun Moo LeeHyun Moo Lee Seoul, Korea, Republic of Korea More articles by this author , and Byong Chang JeongByong Chang Jeong Seoul, Korea, Republic of Korea More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.961AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To introduce step-by-step skills and to show the learning curve of pure laparoscopic adrenalectomy performed by a single surgeon. METHODS From October, 2008 to September, 2011, 74 patients out of 112 who were diagnosed as adrenal mass received pure laparoscopic adrenalectomy. 8 cases were bilateral, and 66 cases were unilateral. After placing the patient in flank position, 12mm camera port is inserted near umbilicus. If the patient is obese, camera port is lateralized. Two 5mm working ports are placed at the cross-sections of midclavicle line, anterior axillary line and subcostal margin. 2mm port for liver retraction is placed just below the xiphoid process if the mass is on the right side. When performing the right adrenalectomy, avascular triangle formed by vena cava, liver, renal vein is identified. Adrenal gland is lifted up using forcep or suction, and adrenal vein is ligated. Inferior phrenic vascular supply at the liver margin and renal hilum vascular supply at the upper pole margin of kidney are secured in order. And then, adrenal gland is removed. When performing left adrenalectomy, line of Toldt, splenocolic ligament and splenic flexure is incised. The plain between descending colon, pancreas, spleen and perirenal fascia is splitted and flipped over all the way to the medial side. After identifying renal vein, adrenal vein is ligated. Following procedures are the same as on the right side. The camera scope is replaced to 5mm and inserted into 5mm working port, and 12mm port is used for delivering specimen. Drain is not inserted. RESULTS There was significant improvement in average operation time(90 vs. 53min, p=0.003) and decrease in estimated blood loss(130 vs, 50mL, p<0.001) of the latter 33 unilateral laparoscopic adrenalectomy cases compared to the prior 33 cases. CONCLUSIONS With the knowledge of anatomical structures near the adrenal glands, the surgical techniques introduced here in this video clip will help the surgeon with little experience on adrenalectomy to overcome the learning curve. Table. Learning curve analysis Case 1-33 Case 34-66 p-value Sex (M/F) 23/10 21/12 0.602a Age (year) 48.48±12.75 50.54±11.32 0.490b BMI (kg/m2) 24.88(22.08-27.55) 26.91(23.19-28.24) 0.284c Laterality (Rt/Lt) 17/16 17/16 1.000a Tumor size (cm) 4.5(2.65-6.00) 3.5(2.05-5.25) 0.313c POD (days) 4.0(3.0-6.5) 4.0(3.0-5.0) 0.698c EBL (mL) 130(50-375) 50(30-100) <0.001c OP time (min) 90(54-137) 53(40-70) 0.003c IntraOp Cx (No/Yes) 28/5 31/2 0.427a a Pearson's Chi-square test, b Student t-test, c Mann-Whitney U test © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e353-e354 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hyung Joon Kim Seoul, Korea, Republic of Korea More articles by this author Hyun Hwan Sung Seoul, Korea, Republic of Korea More articles by this author Bumsoo Park Seoul, Korea, Republic of Korea More articles by this author Bong Hee Park Seoul, Korea, Republic of Korea More articles by this author Seong Il Seo Seoul, Korea, Republic of Korea More articles by this author Seong Soo Jeon Seoul, Korea, Republic of Korea More articles by this author Hyun Moo Lee Seoul, Korea, Republic of Korea More articles by this author Byong Chang Jeong Seoul, Korea, Republic of Korea More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Synchronus paraspinal and hepatic hydatid disease ; a rare presentation

Hydatid cystic disease is a common zoonotic infection in the Indian subcontinent. However in the following case we report a rare presentation found in a young patient synchronously in the paraspinal and intrahepatic location without intercommunication. A high index of clinical suspicion is necessary for diagnosis. Hydatid disease is to Echinococcus species commonly granulosus, sometimes multilocularis. The common locations of hydatid cysts are the liver (65% to 75%) and lungs (25%-30%). Hydatid disease rarely develops in locations such as spleen, kidney, bones, heart, brain, peritoneum, myocardium and muscles (1-4%). A 25 year old male presented with complaining of backache on the right and fullness in the right paraspinal region. On clinical examination he had a non ballotable lump in right paraspinal region within intra muscular plane extending from posterior subcostal margin to iliac region. CT abdomen (P+C) revealed a well defined hypodence non-enhancing cystic lesion in the right lobe of the liver with peripheral calcification with lesion of similar morphology in right paraspinal muscles. Exploration of the right paraspinal region was done. Cyst was beneath the oblique & lattisimus dorsi, superficial to psoas muscle without invasion in it. Cyst opened multiple daughter cysts along with pus evacuated. Cyst excised in totto without spillage. Hydatid cyst is frequently asymptomatic, most prevalent in sheep and cattle-breeding areas. The cysts can not easily grow in muscles due to their contractility and lactic acid content. The latent period of cyst development varies between 5-20 years. Surgery is the optimal treatment for hydatid cysts. Open cyst evacuation is indicated for gharbi types 4&5, posterior cysts, central cysts, more than 3 cysts, infected cysts, biliary communication, pulmonary communication & peritoneal rupture. Alternative therapy with non-toxic scolocidal agents or combination chemotherapy has been advocated in the management of recurrence and high risk of contamination.

Laparoscopy-Assisted Right Hepatectomy and Caudate Lobectomy with Portal Reconstruction for Hilar Cholangiocarcinoma

Introduction: Laparoscopic resection of hilar cholangiocarcinoma remains uncommon because of its technical difficulties.1,2 However, the main site of the operation for hilar cholangiocarcinoma is the right subcostal area, and most procedures, including major hepatectomy and even vascular reconstruction, can be performed through a 10-cm right subcostal incision if mobilization of the liver is carried out laparoscopically. This video demonstrates our novel minimally invasive technique of laparoscopy-assisted right hepatectomy and caudate lobectomy with portal reconstruction for advanced hilar cholangiocarcinoma. Materials and Methods: The patient in the video was an 82-year-old woman who was diagnosed to have hilar cholangiocarcinoma (Bismuth type IV). The patient was placed in left hemilateral position to switch easily between the supine and left lateral position. First, a 10-cm minilaparotomy incision was made at the right subcostal margin. During lymphadenectomy of the hepatoduodinal ligament, the feasibility of the operation was finally confirmed, including the possibility of vascular reconstruction. In the video case, there was portal vein invasion at the level of the bifurcation. Then the right hepatic artery and the common bile duct were divided. Gelport (Applied Medical, Rancho Santa Margarita, CA) was put on the subcostal incision and laparoscopic mobilization of the liver was performed with four trocars added. In addition to the mobilization of the lateral segment and the right lobe, the caudate lobe was completely mobilized from the inferior vena cava. A parenchymal transection was performed using a modified hanging maneuver through the minilaparotomy incision, using the same method as for open liver resection. The left hepatic duct was divided adjacent to the umbilical portion. As we reach the posterior surface of liver, the right hepatic vein was dissected and divided using a linear stapler. After clamping the portal trunk and left portal branch as far from the portal bifurcation as possible, the portal vein was resected and the specimen was retrieved through the minilaparotomy. Portal reconstruction was performed in an end-to-end fashion. Roux-en-Y hepaticojejunostomy was finally performed. Results and Conclusions: A total of three cases underwent laparoscopy-assisted right hepatectomy and caudate lobectomy (with portal reconstruction in one case). The mean operative time was 672 minutes and the mean blood loss was 1047 mL. There were no intraoperative complications. Histological examination of resected specimens revealed curative status with clear margins in all cases. We conclude that this operation is feasible and safe. It should be currently performed with appropriate expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether this approach offers any advantage over the standard open approach. The authors have nothing to disclose. Runtime of video: 7 mins 51 secs

Hepatocellular carcinoma presenting as polymyositis: a paraneoplastic syndrome

Polymyositis as a paraneoplastic syndrome associated with hepatocellular carcinoma is quite rare; only a few cases have been reported. We report a case of a 50-year-old female who presented with subacute quadriparesis, neck muscle weakness, elevated creatinine phosphokinase, a myogenic pattern on the EMG and was diagnosed as having polymyositis, a paraneoplastic syndrome associated with hepatocellular carcinoma with negative hepatic viral markers and a positive ANA. Improvement in patient symptoms and areduction in creatinine phosphokinase, which occurred after lobectomy, supports this rare association.

Reconstruction of the esophagojejunostomy by double stapling method using EEA™ OrVil™ in laparoscopic total gastrectomy and proximal gastrectomy

Here we report the method of anastomosis based on double stapling technique (hereinafter, DST) using a trans-oral anvil delivery system (EEATM OrVilTM) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection.As a basic technique, laparoscopic total gastrectomy employed Roux-en-Y reconstruction, laparoscopic proximal gastrectomy employed double tract reconstruction, and end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum.We used EEATM OrVilTM as a device that permitted mechanical purse-string suture similarly to conventional EEA, and endo-Surgitie.After the gastric lymph node dissection, the esophagus was cut off using an automated stapler. EEATM OrVilTM was orally and slowly inserted from the valve tip, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. Yarn was cut to disconnect the anvil from a tube and the anvil head was retained in the esophagus.The end-Surgitie was inserted at the right subcostal margin, and after the looped-shaped thread was wrapped around the esophageal stump opening, assisting Maryland forceps inserted at the left subcostal and left abdomen were used to grasp the left and right esophageal stump. The surgeon inserted anvil grasping forceps into the right abdomen, and after grasping the esophagus with the forceps, tightened the end Surgitie, thereby completing the purse-string suture on the esophageal stump.The main unit of the automated stapler was inserted from the cut-off stump of the lifted jejunum, and a trocar was made to pass through. To prevent dropout of the small intestines from the automated stapler, the automated stapler and the lifted jejunum were fastened with silk thread, the abdomen was again inflated, and the lifted jejunum was led into the abdominal cavity.When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, DST-based anastomosis was completed with no dog-ear.The method may facilitate safe laparoscopic anastomosis between the esophagus and reconstructed intestine. This is also considered to serve as a useful anastomosis technique for upper levels of the esophagus in laparotomy.

Laparoscopic right hepatectomy and partial resection of the diaphragm for liver metastases

Indications for minimally invasive major hepatectomies have been increasing as experience with these techniques grows. Invasion into the diaphragm is considered a contraindication to the laparoscopic approach. At their institution, the authors have begun approaching all tumors laparoscopically. This report presents the techniques necessary to perform right hepatectomy, partial diaphragm resection, and repair using totally laparoscopic techniques. Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. The hepatic inflow is taken extraparenchymally before transection of the hepatic parenchyma in an anterior-to-posterior fashion. The hepatic inflow then is transected, and the involved portion of diaphragm is transected with ultrasonic shears. Next, the diaphragm is repaired primarily and buttressed with an absorbable material to decrease the incidence of recurrent diaphragmatic hernia. Laparoscopic treatment was attempted for ten patients and successfully completed for nine of these patients (90%). All 10 patients had secondary liver tumors. Three patients required concomitant partial diaphragm resection. The median estimated blood loss (EBL) was 500ml (range, 300-3,000ml). All margins were negative, and the average hospital stay was 8days (range, 5-17days). Two patients (20%) experienced complications, which consisted of biliary leaks, which were treated with percutaneous drainage. One of these patients underwent conversion to an open procedure due to an inferior vena cava injury. No mortality occurred at 30 or 90days of follow-up evaluation. The minimally invasive approach to secondary tumors requiring right hepatectomy is feasible and safe even when there is diaphragmatic involvement. Larger series with long-term follow-up evaluation are needed to determine whether these short-term results translate into durable benefits.

Atypical focal nodular hyperplasia of the liver

Focal nodular hyperplasia, a benign hepatic tumor, is usually asymptomatic. However, rarely the entity can cause symptoms, mandating intervention. We present a case of focal nodular hyperplasia of the liver, which caused a considerable diagnostic dilemma due to its atypical presentation. A 29-year-old woman presented with a 15-year history of a progressively increasing mass in the right upper quadrant which was associated with pain and emesis. Examination showed a firm, mobile mass palpable below the right subcostal margin. A computed tomography scan of the abdomen showed an exophytic mass arising from hepatic segments III and IVb. Trucut biopsy of the hepatic mass was equivocal. Angiography showed a vascular tumor that was supplied by a tortuous branch of the proper hepatic artery. Surgical intervention for removal of the mass was undertaken. Intra-operatively, two large discrete tumors were found and completely resected. Histopathological examination showed features consistent with focal nodular hyperplasia. This description of an unusual case of focal nodular hyperplasia of the liver highlights the point that the diagnosis of otherwise benign hepatic tumors may be difficult despite extensive work-up in some cases.

A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy

INTRODUCTION:Less than 10 mm port-site herniation is a rare complication after laparoscopic surgery. We report a case of complicated herniation through the 5-mm lateral trocar port site.CASE REPORT:A 63-year old obese female was admitted due to intestinal obstruction. She has undergone the laparoscopic cholecystectomy 1 year ago. On examination, abdomen was bloated and roughly 10 cm size mass was palpable on the right subcostal area. Plane radiogram of the abdomen showed signs of intestinal obstruction. Since conservative treatment was ineffective, the patient was operated on. The laparotomy revealed a protrusion of a part of right large intestine and greater omentum into the subcutaneous space through the abdominal wall defect below right subcostal margin. There was a dilatation of intestines proximally incarcerated colon. It was released and a part of omentum was resected. The peritoneum and fascia-muscular defect was closed by interrupted vicryl sutures.CONCLUSION:Acute herniation through a 5 mm size most lateral trocar port site is a rare complication of laparoscopic surgery requiring prompt differential diagnosis.

Renal angiomyolipoma in horseshoe kidney — A surprise diagnosis at laparotomy

A 29-year-old G 3 P 1 +1 woman came for routine antenatal checkup in third trimester. She had no complaints. Her general and obstetric examination showed normality but there was a huge solid fixed lump in the right side of the abdomen. She was advised ultrasonography (USG) for the assessment of fetal well being as well as to evaluate the lump. USG showed a single live pregnancy of 35±1 weeks with asymmetrical fetal growth and more than mild hydramnios. It also revealed a large, ill defined, echogenic mass with small hypoechoic areas in the maternal right iliac and lumbar regions. The appearance was in favor of ovarian dermoid. She was kept under observation. An elective Cesarean section was done after 39 weeks of pregnancy and a male baby of 2.5kg, with apgar score 8 at 1 minutes of and 10 at 5 minutes was delivered. After the closure of uterus a soft solid irregular mass was found on the right side of the abdomen. It extended upto the right subcostal margin from where it could be traced posteriorly. It originated from the right horn of the horseshoe kidney.

Abdominal Wall Hematoma Following Paracentesis

Purpose: Paracentesis is typically a very benign procedure, even in the presence of coagulopathy. We present the case of a 67-year old woman with cirrhosis who underwent a paracentesis and subsequently developed an abdominal wall hematoma. A 67 year old women with ascites secondary to cirrhosis, an INR of 1.38 and platelets of 37, underwent an ultrasound guided paracentesis in the right lower quadrant. No immediate complications were reported but the patient was noted to have a swelling at the paracentesis site few hours after the procedure. This swelling progressively enlarged and by the next morning, the patient had developed a 24 cm x 12 cm tense abdominal wall hematoma extending from the rib cage to the inguinal ligament. The patient was transfused eight units of packed red blood cells and multiple units of platelets and fresh frozen plasma because of the enlarging hematoma, hypotension, tachycardia, pallor and anemia. A diagnosis of abdominal wall hematoma was made on a CT scan of the abdomen (Figure 1) and a surgical consultation was requested for draining the hematoma. Intra-operatively the hematoma was seen extending anterior to and into the rectus sheath all the way from the subcostal margin to the inguinal ligament. Arterial bleeding was not seen and some venous oozing was controlled with electrocautery. The patient tolerated the surgery well but eventually succumbed to a nosocomial pneumonia. Paracentesis is considered a safe procedure even in patients with a coagulopathy. Hemorrhagic complications occur in less than 1% of cases and major hemorrhagic complications requiring transfusions are even rarer. Post procedure bleeding can take the form of intraperitoneal bleeding, inferior epigastric artery pseudo-aneurysm and abdominal wall hematoma, as was the case in our patient. Bleeding during the procedure can result from puncture of superficial epigastric vessels, intra abdominal collaterals or paraumbilical veins. Performing the procedure in the avascular midline under ultrasound guidance can potentially decrease these hemorrhagic complications. Coagulopathy, if present, must be corrected in addition to definitive treatment, which includes surgical drainage of abdominal wall hematomas and embolization of inferior epigastric pseudoaneurysms.Figure

Hepatic steatosis: An experimental model for quantification

Non-alcoholic fatty liver disease (NAFLD) has gained extensive research attention, and the relationship with cardiovascular disease is of great clinical interest. Traditionally, diagnosis of NAFLD is dependent on liver biopsy, but the heterogeneous fatty infiltration may confound the diagnosis. The main purpose of this study was to introduce an experimental method to quantify hepatic steatosis in rats, and to provide an alternative experimental model in following researches. Twenty male Sprague–Dawley rats (6-week-old) randomly divided into two groups and were fed by the commercial chow diet and the choline/methionine deficient (CMD) diet for 2 weeks. All rats underwent a complete morphological measurements and blood biochemistry studies at the beginning of study and 2 weeks later. Two Chinese acupuncture needles were inserted percutaneously into the liver of each rat under general anesthesia for bioelectric impedance analysis (BIA). The acupuncture needles were carefully wrapped by non-conducting sheathes, and were inserted at left subcostal margin and the lower limb of the left rib with the depth of 0.5 cm. All rats were sacrificed with their livers isolated, sampled, sliced and well prepared after BIA measurements were completed. All pathological specimens were interpreted by one single hepatopathologist. With similar weight in the beginning of study, CMD rats were significantly lighter in weight, but had significantly higher liver weight/body weight ratio (5.5% (4.5–6.7%) vs. 4.6% (4.2–5.7%), p = 0.015) 2 weeks later. Serum levels of ALT: 77 (64–125) vs. 53 (40–167) IU/ml, p = 0.019, and AST: 370 (324–420) vs. 282 (217–365) IU/ml, p < 0.001, were significantly higher in CMD rats, but not the lipid profile. Hepatic steatosis was more advanced: 3 (0–3) vs. 0 (0–0), p < 0.001, in pathological staging, and the BIA readings were significantly lower: 15.3 (12–25) vs. 30.5 (14–66) mΩ, p = 0.004, in CMD rats. Steatosis score was significantly correlated with BIA readings ( p < 0.001, γ = −0.52). In conclusion, this experimental model enables researchers to quantify hepatic steatosis with less concern of heterogeneous fatty infiltration, and providing a continuous but not categorical measurement of hepatic steatosis.

Flowers in a bone marrow aspiration

An 18-year-old man from a rural area of Iran, Fars province, presented with fever of unknown origin (FUO) since 1 month prior to admission. On admission, temperature was 38.68C, blood pressure 110/70 mmHg, pulse rate 90 per min, and respiration rate 18 per min. Fever was double quotidian, and was accompanied by profuse sweating. Physical examination revealed a palpable spleen 3–4 cm below the left subcostal margin. There was neither lymphadenopathy nor hepatomegaly. Liver tests show a mild elevation in enzymes as follows: SGOT 49 Iu/L (up to 46 Iu/L), SGPT 50 Iu/L (up to 49 Iu/L), alkaline phosphatase 250 Iu/L (100–290 Iu/L), total protein 7.0 g/dL (5.5–8.0 g/dL), albumin 2.8 g/dL (3.2–5.6 g/dL), g-globulin 4.2 g/dL (2.2–3.5 g/ dL). Complete blood test shows a mild anemia as follows: hemoglobin 11.1 g/dL (13.5–17.5 g/dL), hematocrit 34.2% (41–53%), RBC count 3.89 3 1012/L (4.5–5.9 3 1012/L), WBC count 7.6 3 109/L (4.4–11 3 109/L), platelet count 282 3 109/L (150–450 3 109/L), reticulocyte count 2.1% (0.5–1.5%). C-reactive protein was 34 mg/dL, and erythrocyte sedimentation rate 51-mm/hr. Chest X-ray and electrocardiogram were normal. An abdominal ultrasound confirmed the splenomegaly. Tuberculin skin test and serological tests for syphilis, brucella, CMV, EBV, HIV, and hepatitis viruses were negative. Bone marrow aspiration revealed mild erythroid hyperplasia and a slight increase in eosinophil count; but the obvious finding in bone marrow was numerous Leishman bodies (amastigotes). Surprisingly, amastigotes were mostly in aggregates, forming different shapes resembling as follows: tear drop (Image 1A), clover leaf (Image 1B), ball (Image 1C), sunflowers (Image 1D,E), rossetes (Image 1F), ring and doughnut (Image 1G–I). Such aggregation has not been reported in lymph node aspiration or skin smears [1,2]. The patient received glucantim injections, which subsided the fever within the first week and splenomegaly regressed in the second week. The human stage amastigote is an obligate intracellular parasite, spherical, 2–5 lm in diameter, and displays a nucleus and kinetoplast. Human infection occurs by the bite of the Phlebotomus sandfly and injection of promastigote form into the subcutaneous tissue. They develop into the amastigote form and disseminate through the reticuloendothelial system. Visceral leishmaniasis (kala-azar) (VL) is caused by Leishmania donovani or Leishmania infantum [3]. In Iran, kala-azar mainly occurs in infants and children (infantile kala-azar) and shows a seasonal pattern, appearing from April to October with infection having taken in previous fall [3]. Children 1 to 4 years old are mainly affected. It occurs very rarely in adults. The clinical infection is characterized by chronic fever and hepatosplenomegaly. VL can rarely present with Evans syndrome [4]. The demonstration of the parasite is necessary for the diagnosis of kala-azar. The indirect fluorescent antibody and polymerase chain reaction tests and culture are also helpful in diagnosis. The treatment of choice is meglumine antimoniate (glucantime), given intramuscularly daily for 30 days (10 mg/kg of body weight). Residual spraying with DDT and use of mosquito nets during sleep are recommended to stop transmission by sandflies. VL occurs sporadically in the different geographic areas of Iran [3].

Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy

Oesophagectomy with extended lymphadenectomy carries considerable morbidity due to parietal trauma. It is also technically extremely demanding because the difficult access even through a large thoracotomy requires the use of long instruments to reach the deepest recess in the chest cavity. Since the first thoracoscopic oesophagectomy reported by Cuschieri et al. [1] in 1992, different minimally invasive approaches have been proposed [2-12]. The aim of this video is to show the accurate and relative ease of an entirely thoracoscopic and laparoscopic oesophagectomy with an extended lymph node dissection of mediastinum in prone position (thoracoscopically) and celiac trunk (laparoscopically). Oesophagectomy by thoracoscopy, laparoscopy and cervicotomy was proposed in a 63-year-old man with a lower third oesophageal cancer. General anaesthesia was performed with a double-lumen endotracheal tube and the patient was placed in prone position. Surgeons were positioned at the right side of the patient. Only three trocars were needed. A 10 mm 30-degree angled scope was inserted in the 7th intercostal space on the posterior axillary line and the remaining two 5 mm trocars were inserted in the 5th and 9th intercostal spaces on the posterior axillary line. Prone position allows an excellent visibility of the operative field even in an only partially deflated lung. In order to achieve a good exposure, transitory pneumothorax with CO2 (14 mmHg) was performed. The mediastinal pleura overlying the oesophagus was incised and the arch of azygos vein was isolated, ligated and divided. The oesophagus was circumferentially mobilized from the thoracic inlet down to oesophageal hiatus. Para oesophageal and subcarinal lymph nodes were dissected so as to remain in block with the surgical specimen. A 28 F chest tube was inserted in the 8th intercostal space on the anterior axillary line. In the second stage the patient was placed in supine position and pneumoperitoneum was established. Five trocars were placed along an ideal semicircular line, with the concavity facing the subcostal margin and a 30-degree angled laparoscope was used. The lesser omentum was widely opened up the right pillar of the hiatus. Mobilization of the greater curvature of the stomach was performed preserving the right gastroepiploic artery. A wide Kocher maneuver was performed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. This artery and the left gastric vein were dissected, clipped and sectioned. All fatty tissue and lymph nodes along hepatic artery, left gastric artery and celiac trunk were resected in block with the surgical specimen. Multiple applications of a linear endoscopic stapler were used to create the gastric tube. Finally the distal oesophagus was dissected, until the thoracoscopic dissection field was joined. In the third stage a left lateral cervicotomy was performed and the cervical oesophagus was dissected down to the thoracoscopic dissection plane. Oesophagus and stomach were delivered through the cervical incision and an oesophagogastric anastomosis was created by a linear stapler technique. Cervical and abdominal drainages were installed. The total operative time was 271 minutes (thoracoscopy: 106 minutes, laparoscopy 120 minutes and cervicotomy 45 minutes) and blood loss was about 100 ml. Histological examination demonstrated a squamous cell carcinoma. Both margins of resection were free of tumour and 29 lymph nodes were retrieved. The final stage was IIA (pT3N0Mx). Thoracoscopic and laparoscopic oesophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopic oesophagectomy in prone position improves the quality of dissection because: The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harm's way. For the same reason small to moderate bleeding will not obscure the operative field. Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon. This article contains a supplementary video.

Extensive retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis: An extremely fulminant form of a common disease

As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.