Laparoscopic Entry via the DE-ALWIS METHOD

Despite the rapid advances in laparoscopic surgery in the past 2 decades the initial entry still accounts for approximately 40% to 50% of laparoscopic complications and should be considered the most dangerous step of a laparoscopic procedure. In this review, the authors share a technique for initial umbilical entry, and provide alternative entry sites in cases where umbilical entry is comtraindicated. Rev Obstet Gynecol. 2009; 2(3):193-198 doi; 10.3909/riog0088. Laparoscopy for diagnostic purposes to a modality for minor and major surgical procedures, had been advancing rapidly over the last 3 decades. The initial entry still accounts for about 40-50% of laparoscopic complications and is the most dangerous step of this surgical procedure [1, 2]. Laparoscopic entry using a veres needle followed by a blind insertion of a sharp trocar is the common method used by gynaecologists [3-5]. There is no concensious as to which laparascopic entry is superior and the common recommendation is use the entry methods with which the surgeons feel comfortable [6]. Umbilical entry is not suitable in certain instances, such as previous midline abdominal incision, previous umbilical hernia surgery, previous pelvic peritonitis and so forth, due to the presence of pelvic adhesions. An open surgery does not guarantee against a visceral injury [7].

Total retroperitoneal approach to aortic reconstruction: A novel technique for aorto-enteric fistulae and graft infections

Aorto-enteric fistulae pose a challenging negative outcome of aortic intervention. Treatment involves graft excision, and recently, more enthusiasm has met in situ revascularization over extra-anatomic bypass. This has been traditionally performed through the transperitoneal approach via a midline abdominal incision. We propose an exclusively total retroperitoneal technique in managing this complication with regard to both the vascular and alimentary tract technical aspects of the procedure. This involves exclusion and bypass of the affected segment followed by en-mass resection of the affected segment with the duodenum, and finally, bowel anastomosis. We present a case of an aorto-enteric fistulae illustrating classical radiological findings treated via a flank incision and retroperitoneal technique after a temporizing endovascular stent placement at an outside institution. Peri-operative course was uneventful. The retroperitoneal approach has been shown to be equivalent to its transperitoneal counterpart in many aspects of treating aortic disease. It has also been shown to be superior in others, including but not limited to, faster return of bowel function, decreased respiratory complications, less blood loss and shorter length of stay in the intensive care unit (ICU) and hospital. We recommend adding this approach to every vascular surgeons operative armamentarium when it comes to managing aorto-enteric fistulae. This might be especially helpful in avoiding re-operative planes, thus minimizing blood loss and iatrogenic bowel injury, better aortic exposure, and adequate access to the duodenum.

Axial torsion and gangrene of Meckel’s diverticulum: Case report

Introduction. Meckel?s diverticulum (MD) is the most prevalent congenital anomaly of small intestine. It develops due to the incomplete obliteration of omphalomesenterict duct which normally undergoes obliteration during the seventh week of gestation. In the majority of cases MD is asymptomatic but it may cause various complications, such as bleeding, intestinal obstruction and inflammation. Cases of umbilical sinuses, fistulas and neoplasms related with MD have been reported, but extremely rare gangrene due to its axial torsion, especially in children, as is the case of our patients. Case Outline. An 11-year-old boy admitted to hospital due to 24 hours epigastric pain, vomiting and malaise. After a complete physical examination, and appropriate pre-surgical laboratory and radiographic tests, surgical exploration was performed with a midline abdominal incision. On 60th cm proximal to the ileocecal valve we found a long and in a narrow based ganrenous MD with axial torsion and fibrotic cord extending from the tip of MD to the ileal mesentery. Surrounding ileum had normal appearance. A demarcation and subsequent resection of MD and the surrounding ileum was performed with endto- end ileal anastomosis. Postoperative recovery was successful and the patient was discharged after six days. Conclusion. Axial torsion of MD is presented with non-specific abdominal symptoms and difficult preoperative diagnosis. The choice of diagnosis and therapy is surgical exploration and resection of MD.