Abdominoscrotal Hematocele in an Adult and Its Successful Treatment

Abdominoscrotal hydrocele (ASH) is a variant of hydrocele rare to occur in adults. ASH has two sacs, one in the scrotum and one in the abdomen connected through the inguinal canal. Abdominoscrotal hematocele is a rare complication of ASH. We present a 57-year-old male patient, presented to us in August 2019 to JIPMER, Puducherry, India, with complaints of swelling in the scrotum for 15years and abdominal pain for two months. Both the swellings were soft, and cross fluctuation was present. Imaging confirmed the diagnosis of ASH. We did diagnostic laparoscopy, and the abdominal sac was decompressed and found to have thick brownish fluid suggestive of hematocele. We could demonstrate that both sacs were connected. Due to difficulty in the dissection of the sac, the procedure was converted to an open procedure. Both the sacs were excised, and Lytle’s repair was done for the dilated internal ring. Keywords: Testicular Hydrocele, Scrotal Hydrocele, Hydrocele, Hematocele, Testicular Hematocele, Scrotal Hematoceles, Laparoscopic Surgical Procedure, Laparoscopic Surgery

Encompassing an Emerging Laparoscopic Surgical Procedure for Hinchey III Diverticulitis Into Acute Surgical Care Practice: Our Experience With a Case Report and Review of Literature

In the past decade, there has been emerging data from the West supporting the use of laparoscopic lavage (LL) as a minimally invasive surgical (MIS) technique to treat Hinchey III perforated diverticulitis, rather than previous standard open surgical resection procedures. However, this can only be used in a select group of patients and also requires adequate knowledge and experience of colorectal and MIS techniques. This approach remains novel and rarely practiced in Asia. In this report, we review the current literature and discuss the considerations, outcomes, and limitations of this technique with an illustration of our case report. We report on a case of Hinchey III diverticulitis in a 51-year-old Asian woman who was successfully treated with LL after initial diagnostic laparoscopy in our institution and was discharged on the fifth postoperative day. LL is a colorectal MIS technique that has been evaluated and appears to be effective and has less morbidity compared with Hartmann procedure or primary resection with anastomosis. This technique should be incorporated into our practice for patients with Hinchey III diverticulitis who are suitable for laparoscopy at presentation. With the management of our case, we hence propose a clinical algorithm for adoption of this MIS technique by advocating routine diagnostic laparoscopy in hemodynamically stable patients presenting with gross peritonitis from perforated diverticulitis. This will promote the adoption of LL as a management option for perforated diverticulitis.

Study on the Treatment of Postoperative Pain in Patients Operated for Incisional Hernia by Open or Laparoscopic Approach

Postoperative pain is a common symptom in the postoperative period in patients treated for incisional hernia, often refractory to treatment. The purpose of the this paper was to conduct a comparative study on the need for analgesic medication in patients operated for incisional hernia through a classical open approach and a laparoscopic approach. In this respect, we performed a retrospective observational study over a period of 4 years in which we introduced 92 patients operated for incisional hernia in the Surgery Clinic No. 1 of the Emergency County Hospital Tirgu Mures. For the reconstruction of the abdominal wall we used prosthetic materials (surgical meshes). All patients included in the study received only metamizole sodium as analgesic medication. The patients studied were divided into two groups: group A (consisting of 57 patients where open, classic surgical approach was used) and group B (consisting of 35 patients treated using a minimally invasive laparoscopic approach). It was observed that on the day of surgery and during the first two postoperative days there are no statistically significant differences in the need for analgesic medication between the studied groups. Instead, starting with the third postoperative day, the need for analgesic medication is much lower in patients where laparoscopic surgical procedure was used than in those where open, classic surgical approach was used.

Abstract P287: Endothelial Dysfunction in Small Resistance Arteries of Patients with Severe Obesity: Role of Arginase

Nitric oxide (NO) is produced by endothelial NO synthase (eNOS) using the aminoacid L-Arginine. Arginase (Arg) also uses L-Arginine as substrate, converting it in L-Ornitine and urea. An increased Arg activity causes a progressive L-Arginine depletion, which in turn determines a lower NO bioavailability. Studies in murine models of obesity identify Arg as a determinant of endothelial dysfunction. In this study, we evaluated whether Arg might play a role in determining the lower bioavailability of NO in small resistance arteries isolated from subcutaneous tissue of patients with severe obesity (Ob), split in age groups (younger than 30 aa, range 21-29, n=5; older than 30 aa, range 35-56, n=5) vs normoweight controls (Ctrl younger 30 years, range 20-29, n=5; older than 30 yrs, range 36-58, n=5). Each patient underwent a subcutaneous biopsy during a laparoscopic surgical procedure. Small arteries, isolated from periadvential fat, were evaluated on a pressurized micromyograph. Endothelium-dependent vasodilation (VD) was assessed by acetylcholine (Ach, 0,001-100μM). NO availability was assessed by repeating Ach with L-NAME (100μM). Ach was also infused in the presence of norNOHA (10μM, Arg inhibitor). In Ctrl, VD induced by Ach was inhibited by L-NAME and not modified by norNOHA. Ob younger exhibited a reduced VD induced by Ach vs Ctrl of the same age, a reduced inhibition by L-NAME, and a potentiating effect by norNOHA, which also normalized the inhibitory effect of L-NAME on Ach. In Ob older, VD induced by Ach was reduced vs Ob younger, resistant to L-NAME and not modified by norNOHA. In conclusions, in small arteries from younger Ob, the Arg inhibition improves endothelial function by increasing the NO availability, while in older Ob Arg does not seem to play any role in endothelial dysfunction.

Incarcerated umbilical Littre’s hernia at the trocar site of a previous laparoscopic surgical procedure

Introduction Prevalence of Littre’s hernia (protrusion of a Meckel´s diverticulum through an opening in the abdominal wall) is very low, and Littre’s hernias found in an umbilical site are uncommon. Even rarer are cases of an incarcerated hernia resulting in a surgical emergency. Trocar-site hernias are a relatively common complication after laparoscopic cholecystectomy that develop in association with insertion of wide trocars (usually at the umbilical port). Case History A 63-year-old female with a history of obesity, diabetes mellitus, hypertension, laparoscopic cholecystectomy and open hysterectomy arrived at hospital complaining of acute umbilical pain but with no other symptoms or fever. A painful mass observed was believed to be an incarcerated umbilical hernia at a trocar site used in previous laparoscopic surgery. Emergency surgery was undertaken: the opening of the hernia sac revealed a Meckel’s diverticulum within it. The Meckel’s diverticulum was resected using a stapler, followed by herniorrhaphy and hernioplasty. Postoperative recovery was uneventful. Conclusion An incarcerated umbilical Littre’s hernia at a laparoscopic trocar site has not been reported before. To avoid this complication, we agree with the numerous authors who recommend closure of trocar sites of width ≥10mm

Left-sided Gallbladder in the Era of Laparoscopic Cholecystectomy: A Single-center Experience

The malposition of gallbladder under the liver segment III, defined as left-sided gallbladder (LSG), is an unexpected situation for the laparoscopic surgeon. The purpose of this study is to present our experience in treating patients with cholecystitis and LSG discovered incidentally during laparoscopic surgical procedure. Between 1993 and 2009, 5569 patients underwent laparoscopic cholecystectomy in our surgical department. Their records were reviewed and seven patients revealed having LSG (0.12%). Analysis parameters included demographic data, diagnostic methods, mode of surgery, and postoperative outcome. Mean follow-up was 140 months. Of the seven patients, five were women. Mean patient age was 56.7 years. All patients were referred to our department with clinical symptoms of classic cholelithiasis and the diagnosis was established in all of them during surgery. Laparoscopic cholecystectomy was successful in five patients, while in two patients, a conversion to open procedure was needed. A postoperative complication, i.e., biliary leakage was registered in one patient, which was treated successfully. Laparoscopic cholecystectomy is safe even in LSG, but the surgeon must consider the possibility for more anatomical anomalies, adjust the technique of dissection, and must not hesitate, if in doubt, to strive for conversion to open procedure to avoid serious complications.

An Incidental Finding of Mucinous Colon Cancer by18F-Choline PET/CT Determining a Change in Clinical Management of a Patient with Recurrent Prostate Adenocarcinoma

A 66-year-old-man underwent a PET/CT scan after a biochemical relapse for a prostate cancer previously treated with a laparoscopic surgical procedure which revealed a focal uptake in the posterior wall of sigmoid colon. The biopsy demonstrated a colon cancer with mucinous differentiation producing a shift in clinical priority. To the best of our knowledge this is the first report in the English literature describing the detection by18F-choline PET/CT of a colorectal cancer with mucinous differentiation.

Abstract 85: Low-grade Inflammation Participates on the Enhanced Vasoconstriction to the Endogenous Endothelin-1 in Small Vessels From Obese Patients

Objective: Obesity is characterized by vascular low-grade inflammation, with an augmented endogenous endothelin(ET)-1-mediated vasoconstriction (VC) and a blunted tonic nitric oxid(NO)-mediated relaxation (VD). We evaluated whether TNF-α, localized in the vascular wall and in perivascular adipocytes (PVA), contributes to the VC induced by endogenous ET-1 and whether this action is mediated by an effect on tonic NO release in small resistance arteries from obese patients (Ob) and controls (Ctrl). Method: Sample of visceral fat were obtained in 14 Ob (BMI:42.1±3.7) and 14 Ctrl (BMI:25.4±3.6), matched for metabolic profile and blood pressure values, undergoing laparoscopic surgical procedure. Small arteries were investigated on a pressurized micromyograph. Endogenous ET-1 was assessed by vascular response to BQ-123. TNF-α and NO were assessed by Infliximab (IFX) and L-NAME, respectively. Gene and protein expression of TNF-α, ET-1 and ETA receptors were determined by RT-PCR (gene/reference) and IHC (AU) on arterial wall and in PVA. Results: In Ctrl, L-NAME-induced VC (15.5±0.6%) was not affected by IFX (15.1±0.4%). In contrast, Ob showed a blunted VC to L-NAME (6.0±0.7%; P<0.01 vs Ctrl) which was potentiated (P<0.01) by IFX (12.5±0.8%). In Ob, the VD to BQ-123 (47.0±1.5%) was attenuated (P<0.01) by IFX (29.1±2.4%) and not affected by L-NAME (43,3±0.6%). During IFX co-infusion, L-NAME further reduced the VD to BQ-123 (19.4±3.0%; P<0.01 vs BQ-123+IFX). In Ctrl, VD to BQ-123 was blunted (26.3±1.3%; P<0.01 vs Ob), not affected by IFX (24.1±0.6%) and significantly reduced by L-NAME (12.3±1.1%). Ob showed a significant overexpression of TNF-α respect to Ctrl, either at the level of arterial wall (24.9±19.6 vs 2.8±2.5 AU, P<0.001) or in PVA (2.9±1.8 vs 1.2±0.7 gene/reference, P<0.005). These results were paralleled by a higher arterial expression of ET-1 (45.8±10.3 vs 24.3±15.0 AU, P<0.01) and ETA receptors (69.4±6.0 vs 9.6±2.8 AU, P<0.001) in Ob vs Ctrl. Conclusion: Small vessels of Ob show an enhanced ETA-mediated VC and a blunted NO-mediated VD. An excess of vascular and perivascular TNF-α, coupled with an increased expression of ET-1 and ETA in the vasculature of Ob, contributes to the enhanced ET-1-mediated VC tone partly by an impairment of tonic NO release.

The Pressure Distribution Test System of Doctors’ Hand in Laparoscopic Surgery

A surface pressure distribution test system of a doctor’s hand during a laparoscopic surgery based on LabVIEW was designed. The principle was that real time acquisition of data signal on multi-channel sensors, and using data acquisition card to get the feed back voltage signal from these pressure sensors, and then transferred to a PC. The test system had realized the real time processing and display of the signal on LabVIEW. The pressure detection range was 0-210g. The system could detect the surface pressure real time of the part of a doctor’s hand which contacting the surface of handle during the laparoscopic surgical procedure. This system could also make quantitative evaluation of the contact pressure on the handle of the laparoscopic instruments and provide a reference to ergonomics design of the handle.