The “invisible cholecystectomy”: A transumbilical laparoscopic operation without a scar

Background Looking to further reduce the operative trauma of laparoscopic cholecystectomy, we developed, in patients with no history of cholecystitis and a normal BMI, a scarless operation through the umbilicus. The operative technique, along with the results of the first 10 patients operated in this way, are fully described. Methods 10 female patients underwent transumbilical scarless laparoscopic cholecystectomy. Through the umbilicus, two trocars of 5 mm were introduced parallel to another with a bridge of fascia between them (one for the 5-mm laparoscope and the other for the grasper). With the help of one 1-mm Kirschner wire, introduced at the subcostal line and bent with a special designed device, the gallbladder was pulled up and the triangle of Callot was dissected free, clipped, cut, and the gallbladder was subsequently resected. Finally the gallbladder was taken out through the umbilicus and the umbilicus reconstructed. Results 10 female patients, mean age 36 years (range: 31–49), mean body mass index (BMI) 23 (range: 20–26), after one attack (six patients) or a second attack (four patients) and cholelithiasis confirmed by ultrasonography with no suspicion of inflammation were included in this preliminary study. Mean operative time was 70 minutes (range: 65–85) with no conversions; hospital stay was less than 24 hours with no complications. Conclusion Looking to reduce operative trauma and improve the cosmetic result following laparoscopic cholecystectomy, a transumbilical operative technique has been developed. Results of the operative procedure in a selected group of patients are encouraging with no signs of inflammation and normal BMI. The umbilicus can be developed as a natural port for performing various operative procedures with the help of the traction produced by thin Kirschner wires

Increasing Incidence of Plasmodium knowlesi Malaria following Control of P. falciparum and P. vivax Malaria in Sabah Malaysia

BackgroundThe simian parasite Plasmodium knowlesi is a common cause of human malaria in Malaysian Borneo and threatens the prospect of malaria elimination. However, little is known about the emergence of P. knowlesi, particularly in Sabah. We reviewed Sabah Department of Health records to investigate the trend of each malaria species over time.MethodsReporting of microscopy-diagnosed malaria cases in Sabah is mandatory. We reviewed all available Department of Health malaria notification records from 1992–2011. Notifications of P. malariae and P. knowlesi were considered as a single group due to microscopic near-identity.ResultsFrom 1992–2011 total malaria notifications decreased dramatically, with P. falciparum peaking at 33,153 in 1994 and decreasing 55-fold to 605 in 2011, and P. vivax peaking at 15,857 in 1995 and decreasing 25-fold to 628 in 2011. Notifications of P. malariae/P. knowlesi also demonstrated a peak in the mid-1990s (614 in 1994) before decreasing to ≈100/year in the late 1990s/early 2000s. However, P. malariae/P. knowlesi notifications increased >10-fold between 2004 (n = 59) and 2011 (n = 703). In 1992 P. falciparum, P. vivax and P. malariae/P. knowlesi monoinfections accounted for 70%, 24% and 1% respectively of malaria notifications, compared to 30%, 31% and 35% in 2011. The increase in P. malariae/P. knowlesi notifications occurred state-wide, appearing to have begun in the southwest and progressed north-easterly.ConclusionsA significant recent increase has occurred in P. knowlesi notifications following reduced transmission of the human Plasmodium species, and this trend threatens malaria elimination. Determination of transmission dynamics and risk factors for knowlesi malaria is required to guide measures to control this rising incidence

Safety Profile of L-Arginine Infusion in Moderately Severe Falciparum Malaria

BACKGROUND: L-arginine infusion improves endothelial function in malaria but its safety profile has not been described in detail. We assessed clinical symptoms, hemodynamic status and biochemical parameters before and after a single L-arginine infusion in adults with moderately severe malaria. METHODOLOGY AND FINDINGS: In an ascending dose study, adjunctive intravenous L-arginine hydrochloride was infused over 30 minutes in doses of 3 g, 6 g and 12 g to three separate groups of 10 adults hospitalized with moderately severe Plasmodium falciparum malaria in addition to standard quinine therapy. Symptoms, vital signs and selected biochemical measurements were assessed before, during, and for 24 hours after infusion. No new or worsening symptoms developed apart from mild discomfort at the intravenous cannula site in two patients. There was a dose-response relationship between increasing mg/kg dose and the maximum decrease in systolic (ρ = 0.463; Spearman's, p = 0.02) and diastolic blood pressure (r = 0.42; Pearson's, p = 0.02), and with the maximum increment in blood potassium (r = 0.70, p<0.001) and maximum decrement in bicarbonate concentrations (r = 0.53, p = 0.003) and pH (r = 0.48, p = 0.007). At the highest dose (12 g), changes in blood pressure and electrolytes were not clinically significant, with a mean maximum decrease in mean arterial blood pressure of 6 mmHg (range: 0–11; p<0.001), mean maximal increase in potassium of 0.5 mmol/L (range 0.2–0.7 mmol/L; p<0.001), and mean maximal decrease in bicarbonate of 3 mEq/L (range 1–7; p<0.01) without a significant change in pH. There was no significant dose-response relationship with blood phosphate, lactate, anion gap and glucose concentrations. All patients had an uncomplicated clinical recovery. CONCLUSIONS/SIGNIFICANCE: Infusion of up to 12g of intravenous L-arginine hydrochloride over 30 minutes is well tolerated in adults with moderately severe malaria, with no clinically important changes in hemodynamic or biochemical status. Trials of adjunctive L-arginine can be extended to phase 2 studies in severe malaria. TRIAL REGISTRATION: ClinicalTrials.gov NCT0014736

Secured Independent Tools in Peritoneoscopy

The authors present a simple technique for anchoring instruments, powered lights, and micro machines through the abdominal wall

Adhesion formation after intracapsular myomectomy with or without adhesion barrier.

Objective: To show the prevention of adhesion formation by placing an absorbable adhesion barrier after intracapsular myomectomy. Design: Prospective blinded observational study. Setting: University-affiliated Hospitals. Patient(s): Patients R18 years old with single or multiple uterine fibroids removed by laparoscopic or abdominal intracapsular myomectomy. Intervention(s): A total of 694 women undergoing laparoscopic or abdominal myomectomy were randomized for placement of oxidized regenerated cellulose absorbable adhesion barrier to the uterine incision or for control subjects without barriers. The presence of adhesions was assessed in 546 patients who underwent subsequent surgery. MainOutcomeMeasure(s): Theprimaryandsecondaryoutcomesoftheanalysiswerethepresenceandseverityof adhesions for four groups: laparotomy with barrier, laparotomy without barrier, laparoscopy with barrier, and laparoscopy without barrier. Result(s): Therewasahigherrateofadhesionsinlaparotomywithoutbarrier(28.1%)comparedwithlaparoscopy with no barrier (22.6%), followed by laparotomy with barrier (22%) and laparoscopy with barrier (15.9%). Additionally, the type of adhesions were different, filmy and organized were predominant with an adhesion barrier, and cohesive adhesions were more common without an adhesion barrier. Conclusion(s): Oxidized regenerated cellulose reduces postsurgical adhesions. Cohesive adhesions reduction was noted in laparoscopy

Laparoscopy and Natural Orifice Surgery: First Entry Safety Surveillance Step

Results of this study suggest that surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopic procedures may assist in recognizing complications that might otherwise be missed