Objective: We evaluated the efficiency of 3-dimensional Computed Tomographic Angiography (3D CTA) performed with 64-channel Multidetector Computed Tomography (MDCT) to assess vascular anatomy before laparoscopic gastrectomy.Materials and Methods: 20 patients with early gastric cancer scheduled for laparoscopic gastrectomy were evaluated. Dual phase IV contrast CTA was performed before laparoscopic gastrectomy. Arterial and venous phase images were obtained after rapid infusion of contrast agent with an interval of 15 seconds serially during single breath hold of 31 seconds.Results: In all patients, 3D CTA showed Left Gastric Artery (LGA), Left Hepatic Artery (LHA), Right Gastric Artery (RGA) and Left Coronary Vein (LCV) with celiac trunk. Celiac trunk branching pattern was classified according to Michel’s method and in 18 cases, Michel’s type 1, in 2 cases Michel’s type 2 were identified. RGA was originated from Gastro Duodenal Artery (GDA) in 16 cases, from Superior Mesenteric Artery (SMA) in 2 cases and from Proper Hepatic Artery (PHA) in 2 cases. LCV was draining into Superior Mesenteric Vein (SMV) in 18 cases and into Portal Vein (PV) in 2 cases. In 12 of the cases LCV was coursing dorsal to PHA, Common Hepatic Artery (CHA) and Splenic Artery (SA), in 6 cases LCV was coursing ventral to these vessels and was joined to SMV. In 2 cases whose LCV was draining into PV, it was coursing ventral to CHA.Conclusion: Dual phase CTA is successful to define perigastric vascular structures and reduces the risk of vascular injuries when performed before laparoscopic gastrectomy.

Introduction Metabolically supported chemotherapy (MSCT), is defined as the application of standard chemotherapy protocols concomitant to the administration of pharmacological doses of regular insulin and the development of hypoglycemia, and following fasting starting the previous day. This study aims to present the effects of MSCT on the overall survival of locally advanced and metastatic (stage III and stage IV, respectively), or simply unresectable pancreatic adenocarcinoma patients. Material and methods This study is a retrospective analysis of a prospectively maintained database of patients. It includes all patients that applied to our clinic between July 2012 and December 2014 that were diagnosed with unresectable (stage III-IV) pancreatic adenocarcinoma. The demographic data of all the patients as well as the chemotherapy regimen received, date of treatment initiation, date of disease remission, mortality and overall survival of all patients were analyzed using SPSS 20.0. Patient follow-up was performed by means of CT and PET-CT scans. Results 33 patients, 24(73%) males and 9(27%) females, were included in our study. The majority, 27(81%) patients, had metastatic disease at the time of diagnosis and were stage IV. While 11(33%) of the patients were treated using a gemcitabine-based protocol, 13(39%) received FOLFIRINOX. 9(27%) of the patients were initially treated using gemcitabine, but began receiving FOLFIRINOX following progression as second-line chemotherapy. Statistical analysis revealed a median survival of 19.5 months and a 1-year survival rate of 82.5%. Presently, 18(54%) of the patients remain healthy and alive, free of disease progression with ECOG performance statuses ranging between Grade 0 -1. 4(22%) of these patients ultimately underwent radical pancreatic surgery: 3(17%) having undergone pancreaticoduodenectomies (Whipple procedures) and 1(5%) having undergone a distal pancreatectomy. Conclusion This study demonstrates that a metabolically supported form of applying standard chemotherapy regimens may enhance the overall survival rates of unresectable (stage III-IV) pancreatic adenocarcinoma patients.

With the advent of single-port laparoscopy, the spectrum of abdominal surgeries performed is widening. The retraction of the left lobe of the liver in the upper gastrointestinal procedures is a critical maneuver with its added possible complications. In our study, we used the Cerrahpasa retractor (trademark pending by E. Eyuboglu and T. Ipek) for the retraction of the left liver in 22 patients with a different concept other than using the suturing or silk lace techniques described in previous studies. In our technique, the potential of tearing the liver or other anatomical structures is minimal. We believe that, with the aid of our Cerrahpasa retractor, the problem of liver retraction is being solved by a simple and safe technique.

BACKGROUND/AIMS:Since its original description in 1956 by Rudolph Nissen, minor changes were made in technical details of Nissen fundoplication. After the introduction of laparoscopic fundoplication, in order to reduce the rate of complications, some technical modifications led to the development of 'floppy' Nissen fundoplication.METHODOLOGY:From August 1993 to August 2009, laparoscopic Nissen fundoplication was performed on 2100 patients, 17 of whom underwent classical and 2083 underwent floppy fundoplication. All the operations were performed by the same surgical team. Preoperative work-up included 24-h pH monitoring, esophagogastroduodenoscopy and barium cineradiography. Esophageal manometry was not performed due to the physical impossibility of this tool at our clinic. Key steps of the operation were dissection of the hepatogastric and Laimer's ligament, dissection and closure of the hiatus, and short, floppy Nissen fundoplication. Phrenoesophageal ligament was divided to obtain at least of 4cm of an abdominal esophagus.RESULTS:On the follow-up, dysphagia lasted for 1 month in 5.2% (110), between 1-3 months in 0.7% (16) and more than 3 months in 0.1% (3) of patients. Mortality was seen in 1 (0.05%) patient, and it was related to fatal pulmonary vein injury during perioperative bougienage.CONCLUSIONS:Laparoscopic floppy Nissen fundoplication seems to be a safe and feasible technique for surgical treatment of gastroesophageal reflux disease.

BACKGROUND The division of the short gastric vessels (SGVs) is a common practice during laparoscopic floppy Nissen fundoplication (NF) to achieve an adequate mobilization of the gastric fundus. However, the terminal branches of splenic vessels can also be ligated during SGV division, resulting in splenic infarction (SI). The aim of this study was to evaluate our results with SI as a complication of laparoscopic floppy NF. MATERIALS AND METHODS All patients with direct laparoscopic evidence of SI during laparoscopic floppy NF, between August 1993 and August 2009 and under the care of two surgeons, were included in this retrospective study. RESULTS Over the past 16-year period, 2100 patients underwent laparoscopic floppy NF, and splenic infarction was demonstrated in 20 cases (0.95%). There were 11 women (55%) and 9 men (45%), with a mean age of 35.2 years (range, 25-68). The classic pattern, in all cases, was a small area of infarction, less than 10-15% of the total splenic volume, localized mainly in the upper pole. There were no conversions. The mean length of hospital stay was 1.2 days (range, 1-2). During the follow-up period of 3 months, only 2 patients (10%) had persistent abdominal pain, in which computed tomography demonstrated the infarcted areas involving less than 15% of the splenic parenchyma. All cases were managed succesfully with observation alone. CONCLUSIONS Based on the results, partial SI is a recognizable condition during laparoscopic floppy NF. Conservative therapy and close follow-up, without any unnecessary intervention, is an appropriate management that provides a favorable outcome.

BACKGROUND:Rectus sheath hematoma (RSH) is one of the rare causes of acute abdominal pain. This clinical entity is frequently misdiagnosed and leads to unnecessary surgical intervention. We investigated the critical points of the diagnosis and therapy in preventing these mistakes.METHODS:Five patients (5 females; mean age 67.4; range 53 to 74 years) admitted to the emergency surgery unit and diagnosed as RSH between December 2000 and July 2005 were reviewed retrospectively. Demographic characteristics, medical history complaints and physical examination, laboratory and imaging studies findings were investigated.RESULTS:Four patients had been receiving anticoagulant therapy. All of the cases were complaining of abdominal mass and abdominal pain. In the physical examination painful mass was palpated. In cases anemia determined, the diagnosis was done only by computed tomography (CT) in one case, by ultrasonography (USG) and CT in three cases, and during surgical exploration for acute abdomen in one case. Blood transfusion was administered in all of the cases. In four patients anticoagulant therapies were discontinued and intravenous vitamin K and fresh frozen plasma were administered. In one case bleeding control was done during the operation. While three cases were discharged uneventfully following mean hospital stay of 13.6 days, two cases died on the fifth and seventh days.CONCLUSION:In elderly patients with acute abdominal pain, infraumblical mass, anemia and history of anticoagulation therapy, RSH should be taken into consideration and USG and CT should be performed. Early and accurate diagnosis helps for a successful medical treatment and prevents unnecessary surgical intervention.

Purpose To assess the role of laparoscopy in the diagnosis and treatment of abdominal stab injuries (ASI). Methods Patients who underwent laparoscopic procedures due to ASI were included in the study. Hemodynamic instability, injuries to the posterior trunk, concomitant severe cranial injuries, and prior abdominal operations were considered as contraindication for laparoscopy. Results From January 1997 to March 2006, 88 patients underwent laparoscopic management of ASI. In 45 patients (51.1%), there was no intra-abdominal pathology requiring surgical intervention (nontherapeutic laparoscopy) and 5 patients in this group had no peritoneal penetration (negative laparoscopy). In another 25 patients (28.4%), laparoscopic treatment was performed (therapeutic laparoscopy), including bleeding control in liver, colonic, gastric, and diaphragmatic repairs and intra-abdominal bleeding control. Laparotomy was avoided in a total of 70 (79.5%) patients. In 18 patients (20.5%), laparoscopy was converted to laparotomy. There was no mortality, and except one missed small bowel injury nor perioperative morbidity in patients undergoing laparoscopy. In the laparotomy group, major complications were seen in 7 patients. Conclusions Laparoscopy is safe and efficient in the management of ASI and should be more frequently considered as a therapeutic tool.

BACKGROUND Occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. We report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with stab wounds of thoracoabdominal region. METHODS The patients who underwent thoracoscopic management of thoracoabdominal stab injuries between June 2001-December 2005 were included into the study. The data were retrospectively analyzed. RESULTS Ninety-three patients with abdominal and thoracoabdominal stab wounds underwent videoendoscopic management. Among them, eleven selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. The procedures were performed under general (n=10) or local anesthesia (n=1). Diaphragmatic injuries were repaired by intracorporeal sutures in three cases and bleeding was controlled in another two cases by electrocautery coagulation. The procedures were simply diagnostic in six patients. The mean operating time and hospital stay were 35 minutes and 3.5 days respectively. There was neither intraoperative or early postoperative complication, nor mortality. CONCLUSION Thoracoscopy is a safe and efficient tool in the diagnosis and treatment of diaphragmatic stab injuries.

BACKGROUNDOccult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. We report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with stab wounds of thoracoabdominal region.METHODSThe patients who underwent thoracoscopic management of thoracoabdominal stab injuries between June 2001-December 2005 were included into the study. The data were retrospectively analyzed.RESULTSNinety-three patients with abdominal and thoracoabdominal stab wounds underwent videoendoscopic management. Among them, eleven selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. The procedures were performed under general (n=10) or local anesthesia (n=1). Diaphragmatic injuries were repaired by intracorporeal sutures in three cases and bleeding was controlled in another two cases by electrocautery coagulation. The procedures were simply diagnostic in six patients. The mean operating time and hospital stay were 35 minutes and 3.5 days respectively. There was neither intraoperative or early postoperative complication, nor mortality.CONCLUSIONThoracoscopy is a safe and efficient tool in the diagnosis and treatment of diaphragmatic stab injuries.

Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital or acquired. We present a case of laparoscopic approach to repair an acquired inferior triangle (Petit) lumbar hernia in a woman by using polytetrafluoroethylene mesh. The size of the hernia was 8×10 cm. The length of her hospital stay was 2 days. The patient resumed normal activities in less than 2 weeks. The main advantage of this approach is excellent operative visualization, thus avoiding injury to structures near the hernia during repair. Patients benefit from a minimally invasive approach with less pain, shortened hospital course, less analgesic requirements, better cosmetic result, and minimal life-style interference.

BACKGROUND:Incisional hernias develop in 2 to 20% of laparotomy incisions. Approximately 100,000 ventral hernias are operated on each year in the United States. The reported recurrence rates for open repair are 25-52% for primary and 12.5-19% for mesh repair. Compared to the open technique, laparoscopic repair has low rates of complications and recurrence, greater patient acceptance, and shorter hospital stay.MATERIALS AND METHODS:Between April 1999 and April 2004, we treated 150 patients (111 female, 39 male) with ventral and incisional hernias laparoscopically. Data concerning the age and sex of patients, the location, number, and size of fascial defects, the type of hernias and their contents, the size and type of meshes used in repair, operative time, length of hospital stay, and postoperative complications were collected.RESULTS:Of the 150 patients, 92 had incisional hernias and 58 had umbilical hernias. Polypropylene was used in 85 cases, dual mesh in 40 cases, and composite mesh in 25 cases. The mean age of the patients was 56.0 years (range, 33-81 years). Mean operative time was 63 minutes (range, 30-125 minutes). Mean postoperative hospital stay was 2.5 days (range, 1-15 days). The postoperative complication rate was 8.6% (seroma, paralytic ileus, small bowel injury, and suture-site neuralgia). The mean follow-up period was 32 months (range, 4-60 months). There was a 3% recurrence rate. Three subileus cases were detected during follow-up.CONCLUSION:The laparoscopic approach to ventral and incisional hernias is safe, feasible, and a good alternative to the open approach. Our results are comparable with those of other reports in the literature.

Recombinant human growth hormone and nandrolone phenylpropionate are two different anabolic agents. This study was designed to investigate the effects of these anabolic agents on the healing of ischemie colon anastomosis in rats. METHODS: Seventy adult male Wistar rats were divided into five groups (n = 14). Group I was the sham laparotomy group. In the other groups, surgical procedures consisting of transsection and anastomosis were made at a distance 3 cm from the peritoneal reflection. Group II was the nonischemic control group. Ischemie colon model was produced in the remaining groups. Group III was the untreated control group. Groups IV and V received recombinant human growth hormone and nandrolone phenylpropionate, respectively. Bursting pressure and hydroxyproline levels were measured on the third and seventh postoperative days to evaluate anastomotic healing. RESULTS: Recombinant human growth hormone increased both collagen deposition and bursting pressure significantly at postoperative Days 3 and 7 compared with the sham and untreated control groups (P < 0.005). When compared with the untreated control, nandrolone phenylpropionate significantly increased collagen deposition at postoperative Days 3 and 7 (P < 0.005) and bursting pressure only at postoperative Day 3 (P < 0.005). CONCLUSIONS: Recombinant human growth hormone has more favorable therapeutic effects on the healing of ischemie colonie anastomoses than nandrolone phenylpropionate. Recombinant human growth hormone also improves healing of nonischemic colonie anastomosis.

Morgagni-Larrey hernia is a rare type of diaphragmatic hernia, the diagnosis of which is made incidentally by routine chest X-ray film. We describe a technique for the laparoscopic repair of Morgagni-Larrey hernia which was successfully performed in three adult patients; two women and one man. Two of the patients were asymptomatic and had herniation of only omentum into the right hemithorax; however, one was symptomatic and had herniation of the omentum and large bowel. Tension-free closure of the defects was done using Prolene mesh with a hernia stapler, helical fastener, and Endostitch. There were no early complications and the patients were discharged on the fourth postoperative day. The mean follow-up period was 41 months, and there has been no late morbidity or mortality related to this procedure. Using a laparoscopic approach to repair a Morgagni-Larrey hernia provides an excellent view of the surgical field and allows easy manipulation with minimal surgical trauma, followed by rapid recovery of the patient.

Epiphrenic diverticulum of the esophagus is an uncommon disease. In the light of the benefits of minimally invasive treatment of such a functional disorder, we used the laparoscopic approach for resection of an epiphrenic diverticulum. We found that laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity. It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.

OBJECTIVE:To find out whether pilonidal sinus is more common among obese people.DESIGN:Retrospective study from hospital records.SETTING:Two university hospitals, Turkey.SUBJECTS:419 patients who were operated on for pilonidal sinus disease; and 213 age and sex matched patients with benign diseases other than pilonidal sinus disease and who were not morbidly obese acted as controls.MAIN OUTCOME MEASURES:Comparison of body mass index (BMI) in the two groups.RESULTS:Patients with BMI of 25-30 were classified as overweight (61/419, 15% compared with 28/213, 13%), and those with BMI of 30 or more as obese (7/419 compared with 4/213, 2% in each group). Mean (SD) BMI of patients with pilonidal sinus disease was 26.0 (3.9) compared with 25.6 (3.9) in the control group (p = 0.4).CONCLUSION:Obesity alone is not an important factor in the aetiology of pilonidal sinus disease.

Ectopic thyroid tissue can be seen anywhere along the path of the descending glands, but it is rarely seen in the abdominal cavity. An ectopic thyroid was encountered incidentally in the pancreas of a 50-year-old woman who underwent a bilateral truncal vagotomy and pyloroplasty for a duodenal ulcer. There were no signs or symptoms of a thyroid tumor.