Richterov tip inkarcerirane obturatorne hernije: otežana dijagnostika

Obturator hernia is a rare type of abdominal hernia where herniation occurs through the obturator canal. It develops predominantly in elderly underweight women. It has unspecific early symptoms, which is the reason these hernias are usually discovered only after they have become incarcerated. Incarcerated obturator hernias are usually discovered on abdominal computed tomography (CT) scan or emergency surgery due to bowel obstruction. We present a case of an 85-year-old female patient who was admitted because of intermittent abdominal pain and vomiting. Consecutive upright abdominal x-rays failed to show bowel obstruction. Abdominal CT scan revealed a right-sided incarcerated femoral hernia that was not found during emergency surgery. After laparotomy had been performed, a Richter type of right-sided incarcerated obturator hernia was discovered with a small necrotic area on the small bowel. Bowel resection was performed and obturator hernia was closed with interrupted sutures. The patient recovered without complications. Obturator hernia, due to its rarity and unspecific early symptoms, can still be misleading even to the most experienced surgeons. Delayed diagnosis of obturator hernia can lead to bowel necrosis and perforation with significant postoperative morbidity and mortality.Obturatorna hernija je rijedak oblik abdominalne hernije gdje do hernijacije dolazi kroz obturatorni kanal. Najčešće se javlja kod starijih pothranjenih žena. Rani simptomi obturatorne hernije su nespecifični, što je razlog da se ovakve hernije prepoznaju obično nakon što se razvije inkarceracija. Inkarcerirane obturatorne hernije se najčešće prepoznaju tijekom CT trbuha ili hitnog kirurškog zahvata zbog simptoma mehaničkog ileusa. Ovdje prikazujemo slučaj 85-godišnje bolesnice koja je primljena u bolnicu zbog povremenih bolova u trbuhu praćenih povraćanjem. Uzastopne nativne RTG snimke abdomena nisu pokazale opstrukciju crijeva. Učinjen je CT trbuha gdje se prikazala desnostrana inkarcerirana femoralna kila koja, međutim, tijekom hitnog kirurškog zahvata nije nađena. Nakon što je učinjena laparotomija, pronašli smo desnostranu inkarceriranu obturatornu kilu Richterova tipa s malim područjem nekrotičnog tankog crijeva. Učinili smo segmentnu resekciju tankog crijeva. Kilni otvor je zatvoren pojedinačnim šavima. Postoperacijski oporavak bolesnice je bio uredan. Obturatorna kila, zahvaljujući niskoj incidenciji i nespecifičnim ranim simptomima, može biti zbunjujuća čak i za najiskusnijeg kirurga. Odgođena dijagnoza obturatorne kile može dovesti do nekroze i perforacije crijeva, što sa sobom nosi značajan pobol i smrtnost

Jetreni apsces kao terapijski i dijagnostički problem

Liver abscess still represents a significant clinical entity with mortality rates of up to 10%. Traditional treatment of liver abscesses is open surgical treatment. Recently, percutaneous and laparoscopic drainage has been increasingly used. Still, in spite of these relatively novel techniques and improved imaging, liver abscess can sometimes be difficult to diagnose or treat. Here we present two cases of chronic liver abscess treated at our department. First patient was twice hospitalized in other hospitals without reaching definitive diagnosis. He was admitted at our department because of clinical presentation of sepsis, and definitive diagnosis of liver abscess was established only during open surgery. Second patient was admitted after laparoscopic drainage and repeated percutaneous drainage had failed to resolve his symptoms. In both cases, liver segment resection led to complete healing. These cases indicate that chronic liver abscess can still present a diagnostic and therapeutic challenge.Jetreni apscesi i dalje predstavljaju ozbiljan klinički entitet sa stopom smrtnosti i do 10%. Tradicionalno liječenje apscesa jetre je putem otvorenog kirurškog zahvata, iako se u posljednje vrijeme sve češće rabi perkutana ili laparoskopska drenaža. Usprkos tim načinima liječenja i sve boljim dijagnostičkim metodama apsces jetre ponekad nije jednostavno niti dokazati ni liječiti. Ovdje prikazujemo dva slučaja kroničnog apscesa jetre liječena na našem odjelu. U prvom slučaju bolesnik je bio u dva navrata hospitaliziran u drugim ustanovama pod dijagnozom jetrene ehinokokoze. Kod nas je bio primljen zbog kliničke slike sepse. Cistična tvorba u jetri je dijagnosticirana kao apsces tek tijekom operacije. Učinjena je resekcija VII . segmenta jetre gdje se apsces nalazio. Drugi bolesnik je primljen nakon pokušaja laparoskopske drenaže i više pokušaja perkutane drenaže apscesa. U oba slučaja je učinjena segmentektomija jetre, što je dovelo do izliječenja bolesnika. Ova dva slučaja pokazuju kako kronični jetreni apscesi još uvijek ponekad predstavljaju dijagnostički i terapijski izazov

Antibiotic prophylaxis in patients undergoing colorectal cancer resection

Infekcija rane je i dalje jedna od najčešćih postoperacijskih komplikacija, s posljedičnom produženom hospitalizacijom, dužim oporavkom bolesnika i povećanim troškovima liječenja. Smanjenje incidencije infekcije rane obavlja se na razne načine, uključujući optimalnu preoperativnu pripremu operacijskoga polja, kiruršku tehniku, antibiotsku profilaksu i postoperativno liječenje bolesnika. Iako postoje razni protokoli, optimalna antibiotska profilaksa kod bolesnika s kolorektalnim karcinomom još nije utvrđena. U ovoj studiji smo retrospektivno analizirali bolesnike koji su na našem odjelu operirani radi kolorektalnog karcinoma. Bolesnike smo svrstali ovisno o protokolu antibiotske profilakse u dvije skupine. Skupina A dobivala je gentamicin i metronidazol, a skupina B cefazolin i metronidazol. U obje skupine antibiotska profilaksa započeta je neposredno prije operacije i trajala je 24 sata. Uključeno je 57 bolesnika koji su primali gentamicin i metronidazol te 35 bolesnika koji su primali cefazolin i metronidazol. Učestalost infekcije rane u skupini B bila je 6%, dok je u skupini A, koja je primala gentamicin i metronidazol, bila 24% (p<0,05). Navedeni rezultati upućuju daje kombinacija cefazolina i metronidazola u trajanju od 24 sata učinkovita kao antibiotska profilaksa kod bolesnika s kolorektalnim karcinomom.Surgical site infection remains one of the most frequent postoperative complications, leading to prolonged hospital stay and morbidity as well as increased treatment costs. Efforts to decrease incidence of surgical site infections are various, including improving preoperative skin preparation, surgical technique, antibiotic prophylaxis and postoperative patient management. Optimal antibiotic prophylaxis in colorectal surgery is yet to be determined, although there are various recommended regimes. Patients operated for colorectal cancer at our department were retrospectively analyzed. The patients were grouped according to the antibiotic prophylaxis they received. Earlier group of patients received gentamicin and metronidazole and later group received cefazolin and metronidazole. In both groups antibiotic prophylaxis was initiated immediately before surgery and maintained for 24 hours. 57 patients who received gentamicin and metronidazole and 35 patients who received cefazolin and metronidazole were analyzed. Incidence of surgical site infection in the latter group was 6%, compared with 24% (p<0,05) in the group of patients who received gentamicin and metronidazole. This study indicates that a combination of cefazolin and metronidazole administered for 24 hours is effective as antibiotic prophylaxis in patients undergoing colorectal surgery

Isolated Splenic Metastasis from Colon Cancer – Case Report and Literature Review

Solitary splenic metastases are very rare and sporadic. There are several explanations for this low incidence of splenic metastasis including anatomical, histological and immunological features of the spleen. In this paper we present a case of 70-year-old man with no history of previous diseases who was first operated under the diagnosis of acute abdomen revealing perforated colon tumor of splenic flexure with no metastases at that time. Left hemicolectomy was performed followed by postoperative complications demanding a subtotal colectomy and ileostomy. Primary tumor was classified as Dukes (Astler-Coller)-C2, T4N1M0. Patient was referred to oncologist and received chemotherapy (5FU, Leucovorin). 5 months later continuity of the gut was performed by ileosygmoanastomosis. 2 years after first surgical procedure, a CT scan and abdominal ultrasound, followed by needle biopsy, showed isolated metastasis in spleen, so splenectomy was performed. Pathological findings revealed sharply bordered, partially necrotic tumor inside of spleen tissue, spreading to, but not reaching splenic hilum. Histology showed low to medium differentiated adenocarcinoma tissue with desmoplastic stromal reaction. There were no protrusions of tumor cells through spleen surface. In splenic hilum 4 tumor free lymph nodes were harvested. No additional chemotherapy was conducted. The latest follow up, a year after diagnosis of metastasis showed no signs of cancer disease. Review of the literature showed that long term survival and prognosis of isolated splenic colorectal metastasis after splenectomy are rather optimistic, although these are the cases of distant metastasis. Due to small number of cases reported in literature, definitive conclusions and/or guidelines for the treatment of isolated splenic metastasis cannot be given, but splenectomy and chemotherapy are preferable in the treatment, promising long term survival at least for metachronous metastasis

Laparoscopic surgery at University hospital Department of endoscopic surgery - complications and conversions

Laparoskopski pristup prihvaćen je u potpunosti na području abdominalne kirurgije. Više gotovo i nema klasičnih zahvata koji nisu izvedeni laparoskopski dok su neki, kao što je laparoskopska kolecistektomija, postali zlatni standard u kirurškom liječenju bolesti. Cilj ovoga rada bila je analiza rezultata našeg odjela u laparoskopskoj kirurgiji. Materijali i metode: Na Odjelu endoskopske kirurgije KB Dubrava u 2011. godini izvršeno je 620 operativnih zahvata, od čega 150 laparoskopskih. Od svih laparoskopskih operacija učinjeno je 98 elektivnih i 52 hitna laparoskopska zahvata te su analizirane njihove komplikacije i postotak konverzija. Rezultati: Najčešća operacija među elektivnim laparoskopskim zahvatima bila je laparoskopska kolecistektomija dok je kod hitnih zahvata nešto češće izvođena laparoskopska apendektomija. Uz te operacije, laparoskopski su izvedene još i laparoskopska splenektomija, laparoskopska pericistektomija ehinokoknih cisti jetre i slezene, ekstirpacija simpleks ciste Douglasovoga prostora, laparoskopske suture perforiranoga duodenuma i sigmoidnoga kolona te laparoskopske eksploracije trbušne šupljine, elektivne i hitne. U svim tim operacijama zabilježene su samo tri komplikacije (apsces lože žučnjaka, postoperativni paralitički ileus i krvarenje iz uprapubičnoga porta), uz napomenu da su se sve tri komplikacije javile nakon hitnih operativnih zahvata. Stopa konverzije u elektivnih laparoskopskih zahvata iznosila je 3%, a u hitnih 11%. Zaključak: Laparoskopski zahvati sve više postaju primarna metoda izbora i u elektivnim i u hitnim operacijskim zahvatima. Uz dokazane prednosti laparoskopske kirurgije, kao što je brži postoperativni oporavak i blaži kirurški stres, unaprjeđenjem laparoskopskih tehnika i većom educiranosti osoblja još se više smanjuje, ionako malen, broj postoperativnih komplikacija i stopa konverzija.Laparoscopic approach in abdominal surgery has been fully established and accepted. There is practically no classic abdominal operation that has not been successfully performed laparoscopically, whereas some of them, like laparoscopic cholecystectomy, have long ago become golden standard in treating cholelithiasis and cholecystitis. The goal of this study was to analyze the results in laparoscopic surgery, which had been obtained at our department during 2011. Materials and methods: At our Department in year 2011 the authors had performed 620 surgical procedures, 150 of which were laparoscopic procedures. Of all laparoscopic procedures, 98 were elective and 52 urgent procedures. We analysed complications and conversion rates of those procedures. Results: The most common laparoscopic procedure among elective laparoscopic operations was laparoscopic cholecystectomy, while among urgent procedures it was laparoscopic appendectomy. Some other laparoscopic procedures were also performed, such as laparoscopic splenectomy, laparoscopic pericystectomy of echinococcal cyst of liver and spleen, extirpation of simple cyst from the cavity of Douglas, laparoscopic sutures of perforated duodenum and sigmoid colon and laparoscopic explorations of abdominal cavity, both urgent and elective. Only three complications were recorded (gallbladder abscess, postoperative paralytic ileus and bleeding from the supraumbilical port), and all three complications appeared after urgent procedures. Conversion rate in elective procedures was 3%. Conclusion: The popularity of laparoscopic procedures is increasing in both elective and urgent laparoscopic procedures. Some benefits of laparoscopic surgery, like shorter postoperative recovery and milder surgical stress, have already been established. Advancing laparoscopic techniques and training of surgical staff will bring the, already low, number of postoperative complications and conversion rates to a minimum

Laparoscopic surgery at University hospital Department of endoscopic surgery - complications and conversions

Laparoskopski pristup prihvaćen je u potpunosti na području abdominalne kirurgije. Više gotovo i nema klasičnih zahvata koji nisu izvedeni laparoskopski dok su neki, kao što je laparoskopska kolecistektomija, postali zlatni standard u kirurškom liječenju bolesti. Cilj ovoga rada bila je analiza rezultata našeg odjela u laparoskopskoj kirurgiji. Materijali i metode: Na Odjelu endoskopske kirurgije KB Dubrava u 2011. godini izvršeno je 620 operativnih zahvata, od čega 150 laparoskopskih. Od svih laparoskopskih operacija učinjeno je 98 elektivnih i 52 hitna laparoskopska zahvata te su analizirane njihove komplikacije i postotak konverzija. Rezultati: Najčešća operacija među elektivnim laparoskopskim zahvatima bila je laparoskopska kolecistektomija dok je kod hitnih zahvata nešto češće izvođena laparoskopska apendektomija. Uz te operacije, laparoskopski su izvedene još i laparoskopska splenektomija, laparoskopska pericistektomija ehinokoknih cisti jetre i slezene, ekstirpacija simpleks ciste Douglasovoga prostora, laparoskopske suture perforiranoga duodenuma i sigmoidnoga kolona te laparoskopske eksploracije trbušne šupljine, elektivne i hitne. U svim tim operacijama zabilježene su samo tri komplikacije (apsces lože žučnjaka, postoperativni paralitički ileus i krvarenje iz uprapubičnoga porta), uz napomenu da su se sve tri komplikacije javile nakon hitnih operativnih zahvata. Stopa konverzije u elektivnih laparoskopskih zahvata iznosila je 3%, a u hitnih 11%. Zaključak: Laparoskopski zahvati sve više postaju primarna metoda izbora i u elektivnim i u hitnim operacijskim zahvatima. Uz dokazane prednosti laparoskopske kirurgije, kao što je brži postoperativni oporavak i blaži kirurški stres, unaprjeđenjem laparoskopskih tehnika i većom educiranosti osoblja još se više smanjuje, ionako malen, broj postoperativnih komplikacija i stopa konverzija.Laparoscopic approach in abdominal surgery has been fully established and accepted. There is practically no classic abdominal operation that has not been successfully performed laparoscopically, whereas some of them, like laparoscopic cholecystectomy, have long ago become golden standard in treating cholelithiasis and cholecystitis. The goal of this study was to analyze the results in laparoscopic surgery, which had been obtained at our department during 2011. Materials and methods: At our Department in year 2011 the authors had performed 620 surgical procedures, 150 of which were laparoscopic procedures. Of all laparoscopic procedures, 98 were elective and 52 urgent procedures. We analysed complications and conversion rates of those procedures. Results: The most common laparoscopic procedure among elective laparoscopic operations was laparoscopic cholecystectomy, while among urgent procedures it was laparoscopic appendectomy. Some other laparoscopic procedures were also performed, such as laparoscopic splenectomy, laparoscopic pericystectomy of echinococcal cyst of liver and spleen, extirpation of simple cyst from the cavity of Douglas, laparoscopic sutures of perforated duodenum and sigmoid colon and laparoscopic explorations of abdominal cavity, both urgent and elective. Only three complications were recorded (gallbladder abscess, postoperative paralytic ileus and bleeding from the supraumbilical port), and all three complications appeared after urgent procedures. Conversion rate in elective procedures was 3%. Conclusion: The popularity of laparoscopic procedures is increasing in both elective and urgent laparoscopic procedures. Some benefits of laparoscopic surgery, like shorter postoperative recovery and milder surgical stress, have already been established. Advancing laparoscopic techniques and training of surgical staff will bring the, already low, number of postoperative complications and conversion rates to a minimum

Laparoscopic surgery for large hydatide liver cyst after two previous laparotomies [Laparoskopska operacija velike ehinokokne ciste jetre nakon prethodno učinjene dvije laparotomije]

Laparoscopic surgery for hepatic echinococcosis is a technically difficult and demanding surgical procedure even for the most experienced abdominal surgeon. Surgery is performed after the conservative treatment with albendazole for 28 days. We report a case of laparoscopic partial pericystectomy with biliostasis and omentoplasty in a patient with two previously open surgeries (laparotomies)--right subcostal laparotomy for acute inflammation of the gallbladder and right pararectal laparotomy for perforated gangrenous appendix. The patient underwent extensive laparoscopic adhesiolysis due to pronounced intra-abdominal adhesions to gain access to a large hydatid cyst with the diameter of 11 cm. Laparoscopic surgery is much less traumatic to the patient with a better cosmetic effect

Common Bile Duct Obstruction Caused by the Hydatid Daughter Cysts

Echinococcosis is a human parasitary disease. In 2002, 29 new cases of liver echinococcosis were recorded in Croatia. Liver is the most common site of hydatid cysts. Nine patients with echinoccocal liver disease were operated in our department in 2002. Here we present a case where a patient with verified hydatid cyst in the left liver lobe developed high fever, jaundice, nausea, vomiting and pain in the upper abdomen. The symptoms were initially ascribed to the acute cholangitis. After unsuccessful antibiotic treatment, computerized tomography and endoscopic retrograde cholangiopancreatography (ERCP) were performed, demonstrating daughter cysts in the common bile duct. During ERCP, papilotomy was made and daughter cysts were extracted. Hydatid cyst was surgically removed, and a communication between the cyst and left hepatic duct was noted during surgery. Pericystectomy, choledochotomy, removal of remaining daughter cysts from the common bile duct, and sutures of left hepatic duct were performed. The patient recovered fully after the surgery. One of the possible complications of the liver hydatid cysts is the communication between cyst and the biliary tree. Such communications are usually asymptomatic, but symptoms can also mimic acute cholangitis and jaundice, which may lead to the misdiagnosis of the patient’s condition