Novel Resection System for Direct Endoscopic Necrosectomy of Walled-Off Pancreas Necrosis: Have We Conquered the Final Frontier?

Surgical necrosectomy has been the traditional management for pancreatic necrosis and is done using blunt dissection. However, lack of dedicated endoscopic accessories has been a major limitation in direct endoscopic necrosectomy (DEN). Standard endoscopic accessories cannot effectively remove large necrotic material. Also, diameter of instrument channel of the endoscope limits the ability to use large-diameter graspers that can remove large chunks of necrotic material. In this news, we discuss a recent study that has evaluated a new powered endoscopic debridement system for DEN.

Enhancing esophageal repair with bioactive bilayer mesh containing FGF

We aimed to prepare a bioactive and biodegradable bilayer mesh formed by fibroblast growth factor (FGF) loaded gelatin film layer, and poly ε-caprolactone (PCL) film layer, and to investigate its treatment efficacy on esophageal anastomosis. It is envisaged that the bioactive mesh in in vivo model would improve tissue healing in rats. The full thickness semicircular defects of 0.5 × 0.5 cm2 were created in anterior walls of abdominal esophagus. The control group had abdominal esophagus isolated with distal esophageal blunt dissection, and sham group had primary anastomosis. In the test groups, the defects were covered with bilayer polymeric meshes containing FGF (5 μg/2 cm2), or not. All rats were sacrificed for histopathology investigation after 7 or 28 days of operation. The groups are coded as FGF(−)-7th day, FGF(+)-7th day, and FGF(+)-28th day, based on their content and operation day. Highest burst pressures were obtained for FGF(+)-7th day, and FGF(+)-28th day groups (p < 0.005) and decreased inflammation grades were observed. Submucosal and muscular collagen deposition scores were markedly increased in these groups compared to sham and FGF(−)-7th day groups having no FGF (p = 0.002, p = 0.001, respectively). It was proved that FGF loaded bioactive bilayer mesh provided effective repair, reinforcement and tissue healing of esophageal defects.

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

Purpose The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. Methods A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. Results Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. Conclusion Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

A Feasible Technique in Laparoscopic Excision for Juvenile Cystic Adenomyosis: A Case Report, Literature Review, and Surgical Video

Background: Juvenile cystic adenomyosis (JCA) is a rare uterine lesion. We present the case of a young woman who was diagnosed with JCA and subsequently managed with laparoscopic cyst removal with sharp and blunt dissection. Moreover, we provide a literature review and a surgical video. Case: A 22-year-old nulliparous woman presented with severe dysmenorrhea and was assessed using contrast-enhanced abdominal computed tomography, transvaginal ultrasonography and pelvic magnetic resonance imaging, and diagnosed with a cystic lesion on the left side of the myometrium. She underwent laparoscopic cyst excision and uterine reconstruction. Histology was suggestive of JCA. The dysmenorrhea resolved postoperatively. Conclusion: Surgical resection is the first choice of treatment for cystic adenomyosis, and a laparoscopic approach using scissor forceps is effective.

Laparoscopic Diagnosis and Treatment of Gossypiboma Postconventional Ovariohysterectomy in a Bitch

Introduction. Gossypiboma is a rare surgical complication in small animals. The authors reported the laparoscopic diagnosis and treatment of an abdominal gossypiboma and chronic draining fistula postopen ovariohysterectomy (OVH) unresponsive to medical treatment in a bitch. Case Presentation. The patient had undergone OVH and exploratory laparotomy in other veterinary practice 3 years previously. The animal, presenting a chronic fistula, was then referred to UFSM Veterinary Hospital. Ultrasonographic examination revealed a structure compatible with a granuloma. For the laparoscopic procedure, a 3-port (two at 11 mm; one at 6 mm) access was used. Adhesiolysis and mass removal were performed by blunt dissection and bipolar electrocoagulation. The fistula was treated by mobilising the omentum through it. There were no intra- or postoperative complications. The chronic wound showed first intention healing. The mass was composed of fibrous tissues surrounding one surgical gauze. Discussion and Conclusion. The removal of a retained surgical gauze in the abdomen by laparoscopy has already been described in medicine. However, a laparoscopic approach for treating a fistulous draining tract due to a gossypiboma has not been previously reported in dogs. Laparoscopic exploration of the fistula allowed the use of a pedicled omental flap through infected sites to control chronic infection. Laparoscopic surgery can be used to identify and treat abdominal gossypiboma in dogs, including those with chronic abdominal sinus.

Oblique Lumbar Interbody Fusion From L2 to S1: 2-Dimensional Operative Video

This surgical video demonstrates the technique of an oblique lumbar interbody fusion (OLIF) in the lumbar spine from L2 to L5 as well as an oblique approach to the L5-S1 level. It demonstrates the surgical approach, technical nuances of OLIF, and pearls of the surgery. The video discusses the importance of the release of the disc space to allow for height restoration and deformity correction, endplate preparation to enhance arthrodesis, and appropriate implant sizing. The concept of the approach is the minimally invasive blunt dissection through the abdominal wall musculature and mobilization of the retroperitoneal fat. Unlike the transpsoas approach, the surgery is performed anterior to the psoas, avoiding the lumbar plexus.1 For L5-S1, the approach is still performed in the lateral position but with an oblique approach. A vascular surgeon performs the L5-S1 approach, and the disc space is accessed through the iliac bifurcation.2 The discectomy and interbody fusion are performed similarly to a standard anterior lumbar interbody fusion (ALIF), but in a lateral position and at an oblique angle. The patient consented to this procedure and for filming a video of this case.

Enhancing Esophageal Repair With Bioactive Bilayer Mesh Containing FGF

We aimed to prepare a bioactive and biodegradable bilayer mesh formed by fibroblast growth factor (FGF) loaded gelatin film layer, and poly ε-caprolactone (PCL) film layer, and to investigate its treatment efficacy on esophageal anastomosis. It is envisaged that the bioactive mesh in in vivo model would improve tissue regeneration in rats. The full thickness semicircular defects of 0.5x0.5 cm2 were created in anterior walls of abdominal esophagus. The control group had abdominal esophagus isolated with distal esophageal blunt dissection, and sham group had primer anastomosis. In the test groups, the defects were covered with bilayer polymeric meshes containing FGF (5µg/2 cm²), or not. All rats were sacrificed for histopathology investigation after 7 or 28 days of operation. The groups are coded as FGF(-)-7th d, FGF(+)-7th d, and FGF(+)-28th d, based on their content and operation day. Highest burst pressures were obtained for FGF(+)-7th d, and FGF(+)-28th d groups (p < 0.005) and decreased inflammation grades were observed. Submucosal and muscular collagen deposition scores were markedly increased in these groups compared to sham and FGF(-)-7th d groups having no FGF (p = 0.002, p = 0.001, respectively). It was proved that FGF loaded bioactive bilayer mesh provided effective repair, reinforcement and tissue regeneration of esophageal defects.

Case Report: Direct Visualization of the Nervus Intermedius During the Microvascular Decompression Procedure: Should We Take It Seriously?

Background: Nervus intermedius neuralgia (NIN), known as geniculate neuralgia (GN), is an uncommon cranial nerve disease caused by an offending vessel compressing the nervus intermedius (NI). Microvascular decompression (MVD) has now become a valued treatment approach for NIN because it can resolve neurovascular conflict (NVC) at the root entry zone of the NI. In the era of continuously optimizing and improving the surgical technique of MVD, further minimization of all possible postoperative complications is not only welcome but also necessary.Objective: The aim of this work is to assess the postoperative outcome of direct visualization of the NI during the MVD procedure.Methods: This study retrospectively reviewed the clinical records of a group of seven consecutive patients with NIN who underwent MVD in the period of 2013–2020 in our clinic and 16 studies reported NIN patients who underwent MVD in the period of 2007–2020.Results: In total, 91.3% of all patients experienced immediate and complete relief of cranial neuralgia after MVD. Six of 23 patients have experienced direct visualization of the NI intraoperatively, and 66.7% of those patients had complications such as facial paralysis, dysacousia, or a combination of these conditions postoperatively. Slight surgical approach-related complications such as complaints associated with excessive drainage of cerebrospinal fluid (CSF), nausea and vertigo, and delayed wound union were observed in 80% of the remaining 15 patients, and these symptoms are totally relieved in the telephone and outpatient follow-up after 6 months.Conclusion: Our case series shows that MVD produced immediate pain relief in the majority of NIN patients. MVD carries surgical risk, especially in patients who experience direct visualization of the NI after mechanical stretch and blunt dissection in surgical procedures. Attempts to avoid mechanical stretch and blunt dissection of the compressed nerve were important for intraoperative neuroprotection, especially facial nerve protection

A Case of Abdominal Cocoon Syndrome: A Rare Cause of Small Bowel Obstruction At Aber Hospital in Northern Uganda

Abdominal cocoon syndrome (ACS) is a rare cause of small bowel obstruction characterized by partial or complete encasement of small bowel loops in a thick fibro-collagenous sac. It poses diagnostic difficulties due to the non-specific nature of its presentation and thus in most cases, diagnosed incidentally at laparotomy.The researchers present a case of a 27-year old female Ugandan who presented to a rural hospital in Northern Uganda with complaints of central abdominal pain, failure to pass stool and bilious vomiting for three days. She also had feelings of a peri-umbilical mass. She had several episodes of related obstructive symptoms that would be self-limiting for a year. She had unremarkable past surgical, past medical and past gynecological history. Laboratory investigations were unremarkable.Preoperative diagnosis of small bowel intussusception was made basing on examination and ultrasonography report and the patient was managed operatively. At laparotomy, almost all the small bowel loops were found encased in a thick, whitish, fibrous membrane. There was also marked inter-loop adhesions. The membranous sac was incised and completely removed using both sharp and blunt dissection. Inter-loop adhesions were released solely by blunt dissection.The patient recovered postoperatively and was discharged on the seventh postoperative day.