A rare case of abdominal cocoon

Abdominal cocoon is a rare cause of intestinal obstruction usually diagnosed incidentally at laparotomy. It mani- fests by forming a membrane that typically encases the small bowel loops, leading to mechanical obstruction. Preoperative diagnosis is difficult. The etiology of this condition is not well understood; however, it is a form of chronic irritation and inflammation. METHOD: A 33 years old male, from Bangladesh, presented to our emergency department complaining of abdominal pain, nausea, and vomiting. CT abdomen shows a picture of intestinal obstruction at the level of the small intestine. Intraoperative findings showed encapsulation of small bowel by a dense whitish membrane as a cocoon. Histological exam- ination showed a granulomatous peritonitis and Ascaris Lumbricoides in the bowel resected. RESULTS AND CONCLUSIONS: The preoperative diagnosis of abdominal cocoon is difficult and hence, the diagnosis is usu- ally confirmed by laparotomy. Surgery remains the cornerstone in the management of abdominal cocoon. The pathogen- esis of abdominal cocoon remains elusive and has been associated with several conditions. The initial diagnosis of our patient was bowel obstruction from cocoon syndrome (CT and intraoperative findings) probably primitive, and only his- tologically proved granulomatous peritonitis associated with the presence of the parasite

Primary umbilical endometrioma: Analyzing the pathogenesis of endometriosis from an unusual localization

Objective: This report presents a rare case of symptomatic primary umbilical endometriosis and reviews the literature on the topic with the aim to clarify some questions on the origin of endometriosis. Case Report: A 33-year-old woman with cyclic umbilical bleeding was found to have umbilical endometriosis. She had no history of pelvic or abdominal surgery. There was no past history of endometriosis or endometriosis-associated symptoms. An omphalectomy was performed after explorative laparoscopy to carefully inspect the abdominopelvic cavity and assess any coexisting pelvic endometriotic lesions. Histological examination confirmed the diagnosis of umbilical endometriosis. Conclusion: Umbilical endometriosis is a rare but under-recognized phenomenon. Primary lesions are difficult to recognize, but probably represent an independent nosological entity. The possibility of endometriosis must be considered during the evaluation of an umbilical mass despite the absence of previous surgery. Complete excision and successive histology are highly recommended

Prosthetic strap system for simplified ventral hernia repair. Its results in a porcine experimental model.

Abstract: Introduction Aiming to achieve a simplified ventral hernia repair, a proprietary shaped mesh was experimentally tested in the porcine model. The mesh is structured with a large central body and radiating straps. The friction of the straps passing through the tissues are hypothesized to be adequate to maintain the mesh in place during tissue ingrowth, avoiding classic point fixation while ensuring a wide coverage of the abdomen. Methods The mesh, having 6 radial straps, was placed using a sublay preperitoneal technique in 4 pigs. All straps were passed laterally through the abdominal wall and exteriorized from the skin. The straps were trimmed at the level of the skin, allowing the stumps to recoil into the subcutaneous space. The animal were euthanized at 1 and 4 months to determine the integration of the straps. Results Macroscopically all 24 straps were firmly incorporated within the abdominal wall. The tension free placement of the mesh by using the straps was effective. The friction of the straps passing through the tissues was adequate to keep the mesh well orientated. No dislocation of the implants was observed. The strap system also allowed a broader coverage of the abdominal wall, far beyond the wound opening. Conclusions The described arm system of the described implant seems to be effective in eliminating point fixation of the mesh. The fixation arms seemed to have ensured the mesh stayed orientated in all animals. A very wide lateral mesh placement was accomplished, assuring sufficient defect overlap when shrinkage occurs

Muscle degeneration in inguinal hernia specimens.

There are few articles in the literature reporting the histological changes of groin structures affected by inguinal hernia. A deeper knowledge of this matter could represent an important step forward in the identification of the causes of hernia protrusion. This study aimed to recognise the pathological modifications of muscular structures in autopsy specimens excised from tissues surrounding the hernia orifice. METHODS: Inguinal hernia was identified in 30 autopsied cadavers, which presented different varieties of hernia, including indirect, direct and mixed. Tissue specimens were resected for histological study from structures of the inguinal area surrounding the hernia opening, following a standardised procedure. The histological examination was focussed on the detection of structural changes in the muscle tissues. The results were compared with biopsy specimens resected from corresponding sites of the inguinal region in a control group of 15 fresh cadavers without hernia. RESULTS: Significant modification of the muscular arrangement of the inguinal area was recognized. Pathological alterations such as atrophy, hyaline and fibrotic degeneration, as well as fatty dystrophy of the myocytes were detected. These findings were observed consistently in the context of multistructural damage also involving vessels and nerves. In cadavers with hernia these alterations were always present independent of hernia type. No comparable damage was found in control cadavers without hernia. CONCLUSIONS: The high degree of degenerative changes in the muscle fibres in the inguinal area involved in hernia protrusion described in this report seems to be consistent with chronic compressive damage. These alterations could embody one important factor among the multifactorial sources of hernia genesis. Conjectures concerning its impact on the physiology and biodynamics of the inguinal region are made. The relationship between the depicted degenerative injuries and the genesis of inguinal hernia is also a focus of discussion in this article

A rare presentation of gastric phytobezoar: Simultaneous bleeding and perforation. combined laparoscopic and endoscopic approach. Report of a case

Introduction: Bezoars are intraluminal conglomerates of indigestible foreign materials that accumulate in the gastrointestinal tract. We describe our experience with a patient with gastric perforation and concomitant gastric haemorrhage with severe anaemia, in whom we successfully extracted a giant gastric phytobezoar by cooperative laparoscopic and endoscopic surgery. Case presentation: A 68-year-old man was admitted with melena and septic shock. CT scan revealed a gastric perforation. We performed a combined laparoscopic and endoscopic approach with gastrotomy, removal of the phytobezoar and laparoscopic gastric suture. The suture was examined for leakage with the endoscopic hydropneumatic test to obtain direct vision of the suture and no evidence of leakage by insufflation of the area. Discussion: Gastric bezoars can be managed conservatively, endoscopically or surgically. Endoscopic removal, if effective, would be an attractive alternative for bezoar treatment. Usually endoscopic attempts are unsuccessful because of the large size of the bezoar and the difficulty in fragmentation. The laparoscopic approach for bezoar seems to have better postoperative outcomes. The main criticisms of the technique are abdominal spillage with risk of contamination as well as longer operative times. Conclusion: In our case we simultaneously performed laparoscopic surgery and endoscopic operative procedure in accordance with the principles of laparoscopic and endoscopic cooperative surgery to treat the gastric bezoar in order to overcome the limits of a single technique

Role and outcomes of laparoscopic cholecystectomy in the elderly.

Introduction: Laparoscopic cholecystectomy is the standard of treatment for gallstones disease and acute colecystitis. The prevalence of this disease increases with age and the population is aging in industrialized countries. So, in this study we report our experience in the treatment of gallstone disease in elderly patients, particularly analyzing the outcomes of laparoscopic approach. Methods: Between January 2010 and May 2014 we performed a total of 1227 cholecystectomies. In this retrospective study age group was the primary independent variable: 351 patients were 65-79 years of age and 65 were 80 years of age or older. Results: Only 65 patients (5.3%) of all population had primary open cholecystectomy, but the rate in young group was 3.7% respect the highest frequency (9.2%) in the elderly group. The conversion rate was higher (1.2%) in the older group but there was no significant difference with younger group. LC in emergency setting was performed in 10.3% of young patients and in 13.8% of elderly group. Conclusion: Laparoscopic cholecystectomy is a feasible and safe procedure in elderly patients and might be performed during the same hospitalization like definitive treatment of gallstone disease. The old age and subsequent comorbidity are the fundamental predictor of surgical outcomes. Elective treatment should be recommended when repeated gallstone symptoms have occurred in the elderly patient before the development of acute cholecystitis and related complications

Nerve degeneration in inguinal hernia specimens

BACKGROUND: The histological study of the herniated inguinal area is rare in the literature. This report is focused on the detection of structural changes of the nerves within tissues bordering the inguinal hernia of cadavers. Their physiopathological consequences are hypothesized. MATERIALS AND METHODS: Primary inguinal hernia was diagnosed in 30 fresh cadavers. Tissue specimens from the inguinal region close to and around the hernia opening were excised for histological examination. A control of the data was achieved through tissue samples excised from equivalent sites of the inguinal region in 15 cadavers without hernia. RESULTS: The detected nerves in the inguinal area demonstrated pathological changes such as fibrotic degeneration, atrophy, and fatty dystrophy of the axons. The thickening of the perineural sheath was constantly seen. These findings were consistently present, independent of the hernia type. CONCLUSIONS: The detected nerve alterations lead us to imagine a worsening, or even the cessation, of the nervous impulse to the muscles, leading to atrophy and weakening of the abdominal wall. This could represent one of the multifactorial causes of hernia genesis

Damage to the vascular structures in inguinal hernia specimens.

BACKGROUND: Few scientific reports to date describe the histological modification of structures outlining a hernia opening. This article is focused on the identification of the pathological changes in vascular structures in tissues excised from cadavers with inguinal hernia. A deeper comprehension of this topic could lead to essential improvements in the detection of hernia genesis. MATERIALS AND METHODS: Different kinds of hernia, including indirect, direct and mixed, were identified in 30 autopsied subjects. Tissue samples were resected for histological study from abdominal wall structures close to the hernia opening. Histological examination focused on the detection of structural changes in arteries and veins. The results were compared with tissue specimens excised from equivalent sites of the inguinal area in a control group of 15 fresh cadavers without hernia. RESULTS: Significant modification of vascular structures were identified in the tissue specimens examined. The veins demonstrated parietal fibrosis, perivascular edema and vascular dilation due to congestion and stasis. The arterial structures detected showed thickening of the media due to medial hyperplasia, ranging from luminal sub-occlusion to a manifest artery occlusion. These findings are present independent of hernia type in cadavers with inguinal hernia. These pathological changes were lacking in the control group of cadavers without hernia. CONCLUSIONS: The notable changes in vascular structures described in the report could be the result of a steady compressive effect exerted by the abdominal viscera in the inguinal area. These pathological changes could represent one of the factors involved in the weakening of the inguinal region leading to hernia protrusion

Laparoscopic management of adrenal tumors: a four-year experience in a single center

AIM: Today laparoscopy is considered the first choice treatment of many adrenal tumors, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS: From January 2009 to February 2014 we performed 42 lateral transperitoneal laparoscopic adrenalectomies. The indications for surgery were non-functioning adenoma larger than 4 cm or rapid growth and hormone-secreting tumor. The diagnosis was confirmed in all cases with computed tomography and magnetic resonance imaging and also metaiodobenzylguanidine scintigraphy if pheochromocytoma was suspected. In all cases we realized a complete preoperative hormonal study. We describe and analyzed retrospectively: age, side, indication for surgery, tumor size, length of hospital stay, complication and conversion rate. RESULTS: Twenty-two patients with functional tumors and 20 with non functional tumor were subjected to laparoscopic adrenalectomy. There was no conversion to open surgery. Mean operative time was 120 min and estimated blood loss was 80 mL (range 50-350). There was no mortality or major complications. The average length of hospital stay was 3.5 day. During pheocromocitoma removal hypertension occurred in 2 cases. Patient with aldosteroma became normotensive and no required postoperative antihypertensive therapy. CONCLUSION: Laparoscopic adrenalectomy is a standard safe procedure for adrenal surgery. The risk of encountering incidental adrenal cortical cancer increases for large lesions and additional attention is required in these cases to observe oncologic surgical principles. Pre-operative work –up has a primary role in adrenal surgery. An accurate management of adrenal tumors requires an agreement among radiologist, endocrinologist, oncologist and surgeon. Previus abdominal surgery does not constituite a contraindication to laparoscopic transperitoneal adrenalectomy

Robotic versus laparoscopic sacrocolpopexy for apical prolapse: a case-control study

The apical prolapse has always been considered the most complex of the defects of the pelvic floor, for both the difficulty of the surgical corrective technique and for the high post-surgical recurrence rate. Today, the laparoscopic sacrocolpopexy can be considered the standard treatment for apical prolapse. In the last years, several author performed robotic sacrocolpopexy, obtaining positive results. So, we developed a casecontrol study in order to compare the surgical outcome of robotic group with a control group of laparoscopic approach in patients with symptomatic apical pro-lapsed between January 2015 and December 2015 at University Hospital Policlinico "P. Giaccone" and Ospedali Riuniti "Villa Sofia-Cervello", Palermo. Our experience shows that robotic sacrocolpopexy can be considered in positive way for clinical results obtained: all procedures were executed with no complications, we noted a lower intraoperative blood loss and a shorter hospital stay than in laparoscopic group. Although the mean operative time and the economic costs are higher in robotic surgery, this study demonstrates that the use of robotic platform for repairing of symptomatic apical vaginal prolapse is feasible, safe and associated with short-term satisfactory results, representing therefore a valid alternative to laparoscopic approach