Journal of Surgery

Initially used for diagnostic, laparoscopy has become a method of treatment in the field of gynecological surgery, but also in many other fields. The results of laparoscopic surgery are now comparable with those obtained by laparotomy in benign and malignant pathologies. Laparoscopy provides improved results in the short term and at least equivalent results in terms of long-term recurrence when compared with open surgery. Robotic-assisted laparoscopy was performed to prevent the disadvantages of conventional laparoscopy. It emerged as a revolutionary technology and has spread in less than a decade in many surgical fields, including urology, cardiothoracic surgery, pediatric surgery and general surgery. Minimally invasive techniques provide a lower rate of complications during surgery as compared to open surgery, which is appropriate tissue due to handling and better anatomical views. Laparoscopic treatment of cervical cancer provides benefits on increasing comfort with decreased convalescence time, but these cases should be reserved for surgeons with extensive experience in laparoscopic procedures. One of the most important advantages of minimally invasive surgical techniques is the short duration of hospitalization.

The intraductal papillary mucinous neoplasm (IPMN) is a proven precursory lesion of pancreatic cancer, maybe the most important. The pancreatic cancer is a pathology associated with high rates of mortality. The IPMN develops from the epithelial ductal pancreatic cells and it expresses as cystic dilation of the main pancreatic duct and/or its branches, being part of the differential diagnosis of the cystic pancreatic masses. The identification of “invasive” and high-grade dysplasia IPMN lesions is imperiously necessary for a correct therapeutic approach; the pancreatic complementary resection being indicated in all cases with high-grade dysplasia upon the surgical margins of frozen section examinations.

Background: Single-incision laparoscopic appendectomy (SILA) has become an accepted alternative to conventional multiport laparoscopic appendectomy. Yet, little is known about the impact of operations performed by residents on the outcome of SILA. The aim of the present study was to evaluate the safety and efficacy of SILA performed by younger surgeons.

Methods: All SILA's at a single institution were reviewed and grouped according to the educational level of the operating surgeon: group 1 included residents with no experience in single-incision laparoscopic surgery (SILS) and little experience in multiport laparoscopy, group 2 comprised fellows with experience in multiport laparoscopy but with no experience in SILS, and group 3 consisted of senior surgeons, all of whom were experienced in performing SILS.

Results: A total of 176 patients were included. The patients had been operated on by residents (n=62), fellows (n=21), or senior surgeons (n=93). Senior surgeons performed the operation in less time than fellows or residents (48.7 vs. 55.4 vs. 53.6 minutes, respectively; p=0.108). Six patients required conversion to multiport laparoscopy while no patient required conversion to the open procedure. The overall postoperative morbidity was 9.1%, with no significant difference between the three groups (p=0.536). The surgeon's level of surgical education was no statistical risk factor for developing postoperative complications after SILA.

Conclusion: Although operating times were longer for residents and fellows compared to senior surgeons, less surgical experience did not correlate with a greater need for conversion to multiport laparoscopy and was not associated with a higher rate of postoperative complications.

Objectives: The aim of this study was to access the feasibility and benefit of minimally invasive surgery for Small Bowel Obstruction in a tertiary hospital in Trinidad and Tobago.

Design and Methods: All patients with clinical and radiologically diagnosed small bowel obstruction, who had nil resolution with conservative management at 48 hours, or who had nil passage of oral contrast into the colon at 12 hours, were included in this case series. Exclusion criteria included: anesthesiological contraindication for laparoscopy. The primary endpoints were resolution of obstruction (time to first bowel movement, time to commencement of oral feeds) and length of hospital stay. Secondary endpoints included overall morbidity and operative complications (bleeding, subphrenic or pelvic intraabdominal abscesses, wound infections, respiratory complications), during and after hospitalisation.

Results: There were five (5) patients who meet the inclusion criteria for this case series from January 2014 to March 2015. 40% (2/5) of the patients were female. The mean age was 38.4 yrs. Conversion rate was 0%. The enterotomy rate was 20% (1/5). The median duration of postoperative ileus was 5 days. . The median duration of postoperative hospital stay was 5.6 days, mean time to enteral feeds was 1.8 days. Rate of post-operative complications was 20% (1/5).

Conclusion: With appropriate patient selection, minimally invasive surgery is a safe alternative to open surgery for SBO, with acceptable morbidity and mortality.

Seminoma in undescended testes may present as right iliac fossa mass. A seminoma in a 49 year old man with ipsilateral undescended testis is presented and relevant literature is reviewed. A 49 year old male presenting with a right iliac fossa mass was admitted to our hospital and initial diagnostic tests followed by abdominal computerized tomography (CT) were performed. Abdominal CT clearly demonstrated the tumor location. He underwent surgery and the tumor was not operable and biopsy was taken. Pathological diagnosis was consistent with classical seminoma. He was referred to oncology clinic after discharge. Tumors of undescended testis can present as a right iliac fossa mass and clinicians must be aware of their existence.

Introduction: Complications in the evolution of digestive tract benign pathology leads to symptoms: hemorrhagic, occlusive or perforative syndrome.

Method: We present three cases of gastrointestinal (GI) hemorrhage with a different pathology and rarely seen in clinical practice in patients treated with non-steroidal anti-inflammatory drugs for muscular-articular pathology. Cases’ presentation: (1) A 47 years old man known with recurrent episodes of upper GI bleeding was admitted for a new massive hemorrhage; the emergency laparotomy revealed a splenic arteriovenous fistula penetrating the Wirsung duct. A splenopancreatectomy was performed with uneventful recovery. (2) A 57 years old woman with chronic anemia, nausea, weight loss and vomiting was admitted for intermittent recurrent episodes of melena. The exploratory laparotomy revealed several jejunal diverticulum with active bleeding; a segmental enterectomy was performed with uneventful recovery. (3) A 24 year old patient was admitted for massive inaugural melena. The upper GI tract endoscopy was negative; due to hemorrhagic shock an emergency exploratory laparotomy was performed and revealed a jejunal GIST. The resection was performed with uneventful recovery. The histo-pathologic exam confirmed a benign GIST.

Conclusions: During Non-Steroidal Anti-inflammatory Drugs (NSAID) therapy anemia and upper GI bleeding are usually considered as common disorders related with peptic ulcer. However NSAID therapy can hide another more complex causes of bleeding. In majority of cases the bleeding is brutal and surgical approach remains the only alternative to perform the diagnosis and to cure the patient.

Introduction: Even if the prevalence of peptic ulcer disease has decreased in the last years, duodenal perforation remains a life threatening complication. The duodenum is the second most common site of gastrointestinal perforations after the colon and perforation of the 4th portion is very rare.

Case Presentation: A 67-yers-old man was admitted to the emergency department of the Annecy Hospital with intense abdominal pain, vomiting and no transit for the last 24 hours. The laboratory count showed an inflammatory syndrome. A CT scan revealed free air and fluid near the Treitz’s angle. An exploratory laparotomy was performed that revealed a perforation of the forth portion of the duodenum. A duodenal resection with duodeno-jejunal anastomosis was performed.

Discussions: Peptic ulcer disease is a common disease and the perforation is one of its most life threatening complications. The localization of the DP on the forth segment of the duodenum is very unusual. The most frequent localization of DP is the first duodenal segment. Abdominal CT scan is the most sensitive radiological exam if there is suspicion of a DP. A Zollinger-Ellison syndrome must be taken into count. Peritonitis is an indication for immediate laparoscopy or laparotomy, taking into account the patient’s condition. Despite the successful medication therapy and the progress in treatment of duodenal ulcer, perforation remains a serious complication, requiring an emergency surgical treatment.

Conclusion: Duodenal perforation of the fourth portion is an extremely rare complication of the peptic ulcer disease and the surgery is the primary modality of treatment.

Pancreatic pseudocyst is a complication of acute or chronic pancreatitis. The invasive treatment (surgical or endoscopic) is recommended if the pseudocyst persisted for more than 6 weeks after the diagnosis and if the size is larger than 6 cm and is symptomatic. The laparoscopic techniques have been developed to provide the patient with the benefits of a minimal access alternative. The aim of this article is to analyze the postoperative results of the pancreatic pseudocyst laparoscopic surgery. We have accomplished a restrospective study using clinical and para-clinical test results and postoperative results from the patients who have been treated with laparoscopic drainage. We reported a case of a large symptomatic pseudocyst after an attack of gallstone pancreatitis. Laparoscopic cholecystectomy and extern drainage have been performed at the same time with good postoperative results. Starting with year 2000 until year 2015, 85 patients, diagnosed with pancreatic pseudocyst, have been treated in the First Surgical Clinic, University Hospital Saint Spiridon Iasi. From which only 8 have been treated with laparoscopic drainage, encountering no mortality and morbidity. Postoperative hospital stay was 9,41 days. The postoperative drainage duration was between 5 and 21 days with a mean of 7 days. Late postoperative results were good in 6 patients and mediocre in the 2 patients. Conclusion: The laparoscopic technique has all the benefits of the minimal invasive approach. Better postoperative results were seen in cysto-digestive anastomosis using a Endo GIA stapler.