CRSLS : MIS case reports from SLS最新文献

Introduction: Benign prostatic hyperplasia (BPH) affects a significant proportion of aging males, often requiring surgical intervention when conservative treatments fail.

Case description: This case report details the management of a 58-year-old male with severe lower urinary tract symptoms and a markedly enlarged prostate, presenting with bladder stones and persistent obstruction despite medication. The patient underwent an open simple prostatectomy but developed bladder neck contracture and recurrent urinary retention, necessitating a suprapubic cystostomy. Following this, a robotic-assisted approach was chosen to address the complex contracture. The surgical strategy involved a vertical posterior bladder incision, after guide wire was visualized a bladder stone was removed, resection of inflammatory tissue, and a novel 360-degree running suture with 3-0 thread for bladder neck reconstruction. This approach was followed by closure with a double-layer running suture using 3-0 V-Lock material. The patient showed significant improvement in urinary flow and symptom resolution postoperatively, with no residual contracture detected on follow-up imaging.

Discussion: This report highlights the effectiveness of the robotic-assisted technique and the innovative use of the 360-degree running suture for managing challenging bladder neck contractures, marking a novel application in surgical practice.

Background: Obesity is an alarmingly increasing global public health issue. Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery owing to its simplicity, effectiveness, and low complication rates. The complications can be classified as early or late, with fistula formation being one of the most severe complications. Here, we report a rare gastrobronchial fistula (GBF) that presented 12 years post LSG.

Case presentation: A 34-year-old woman who underwent LSG in 2011 was referred to our institution. The patient complained of recurrent upper respiratory tract infections, nausea, and vomiting. Abdominal computed tomography (CT) with oral contrast showed abnormal fistulous communication between the fundus and left lung. Conservative management was initiated but failed multiple times. After counseling the patient on the surgical options, she underwent fistula removal and primary repair of the fundus with a healthy omental wrap and an omental diaphragmatic flap. She tolerated the procedure well, recovered uneventfully, and was discharged on postoperative day 7.

Conclusion: GBF diagnosis is challenging. Imaging studies, such as CT and radiography with contrast and endoluminal diagnosis with esophagogastroduodenoscopy (EGD), bronchoscopy, and bronchial secretion analysis, aid in the diagnosis. GBF management requires a multidisciplinary team. Patients should be initially offered conservative management with the understanding that reoperation would be the only option if failure is seen for 3 months.

Introduction: Acute appendicitis and acute cholecystitis are two of the most commonly encountered surgical entities. Multiple hypotheses are behind their coexistence, which include pathogen predilection, and mucosal ischemia inducing portal vein bacteremia as the management of uncomplicated acute cholecystitis and acute appendicitis is surgical, for which a single operation for synchronous presentation is effective. Here, we report a case with coexistent acute cholecystitis and acute appendicitis managed at our institution.

Case/technique description: A 30-year-old female presented with right upper quadrant abdominal pain for four days. The pain was radiating to the right shoulder, not related to fatty foods, associated with vomiting, anorexia, and burning micturition. On examination, she was vitally stable and afebrile with soft nondistended abdomen, a negative Murphy's sign, right lower quadrant rebound tenderness, and suprapubic tenderness. Laboratory tests showed leukocytosis (17.59 × 10⁹) and high ALT (40 IU/L) and AST (32.5 IU/L). Ultrasound showed a distended gallbladder with two echogenic intraluminal nonshadowing echogenicity, the largest measuring 0.57 cm. Due to the vague presentation we elected to go for computed tomography of the abdomen which showed a distended gallbladder with adjacent fat stranding, subhepatic appendix with distended tip and no surrounding fat stranding. She underwent diagnostic laparoscopy with cholecystectomy and appendectomy. The patient had an uneventful postoperative course and was discharge home on day 1.

Conclusion: We aim to shed light on the rare, but possible, synchronous coexistence of these diseases, raise the index of clinical suspicion. Management options for synchronous presentation can follow their asynchronous guidelines such as Tokyo and WSES.

Introduction: It is rare for adult female patients to present with incarcerated inguinal hernias containing ovary, fallopian tube, or uterine tissue. Potential surgical treatment options for incarcerated inguinal hernias containing ovary, fallopian tube or uterine tissue include open inguinal hernia repair (IHR), laparoscopic or robotic IHR.

Case description: Herein, we report a case of an adult female presenting with a unilateral incarcerated inguinal hernia containing ectopic pregnancy. Patient was treated with laparoscopic lysis of adhesions, reduction of incarcerated ectopic pregnancy and unilateral salpingectomy. Patient then underwent robotic assisted transabdominal preperitoneal IHR (rTAPP-IHR).

Discussion: Minimally invasive laparoscopic salpingectomy and rTAPP-IHR can be safely performed in patients presenting with unilateral incarcerated inguinal hernia containing ectopic pregnancy.

Introduction: There is a risk of iatrogenic vascular injuries during robotic-assisted laparoscopic excision of diaphragmatic endometriosis. Although studies are limited, the first reported case of a suprahepatic inferior vena cava (IVC) injury during robotic diaphragmatic endometriosis excision was successfully treated using a fibrin sealant patch, preventing exsanguination and conversion to laparotomy.

Case description: A 36-year-old female with a history of recurrent catamenial pneumothorax and two prior video-assisted thoracoscopic surgeries to treat diaphragmatic endometriosis presented to our clinic with right-sided shoulder pain and a chest tube in place. She underwent robotic-assisted laparoscopic pelvic and bowel resection for severe endometriosis and liver mobilization to repair the right diaphragm. During liver mobilization, the surgeon inadvertently caused a 2-mm defect in the suprahepatic IVC, resulting in 250 mL of venous hemorrhage. Hemostasis was achieved using robotic compression of a fibrin sealant patch, avoiding conversion to laparotomy. The chest tube was maintained throughout surgery and postoperatively for drainage. The patient experienced no thrombotic complications.

Discussion: This case illustrates the successful use of a fibrin sealant patch to control a major vascular injury in the robotic-assisted laparoscopic setting. While fibrin sealant patches are Food and Drug Administration-approved for soft tissue hemostasis, their application in major vascular repairs, including the IVC, is off-label. The blood loss (250 mL) and absence of thrombotic events highlight the safety and efficacy of the fibrin sealant patch. Further investigation is warranted to establish the efficacy of fibrin sealants in the repair of major vascular injuries in robotic-assisted and traditional laparoscopic surgeries.

Introduction: Acquired ovarian torsion is an uncommon gynecologic emergency that afflicts women of reproductive age and requires correction by surgery. A rare complication of asymptomatic ovarian torsion can be necrosis and autoamputation of the adnexal structures.

Case description: A 28-year-old nulliparous woman presented with irregular menses since puberty associated with dysmenorrhea, menorrhagia, and nausea, and that did not improve with trials of oral hormone therapy. Ultrasound and pelvic MRI revealed a large, tubular-cystic mass separated from the right ovary and tubo-ovarian junction. Intraoperative findings revealed filmy adhesions and fimbriae emanating from this cystic lesion, as well as dilation of the medial portion of the right fallopian tube. Histopathology reported dilated, cystic structures with focal tubal-type epithelial lining, and a dilated fallopian tube lumen, consistent with hydrosalpinx.

Discussion: Autoamputation of fallopian tube is a rare but serious complication of adnexal torsion that should be treated promptly via intraoperative detorsion.

Introduction: A large epiphrenic esophageal diverticulum can cause troublesome symptoms for patients, including dysphagia and reflux, ultimately, leading to debilitating weight loss.

Case description/technique description: We present a case of a 68-year-old female with a history of systemic lupus erythematosus presented with a large epiphrenic esophageal diverticulum with dysphagia, gastroesophageal reflux disease, and associated weight loss. The patient underwent a robotic-assisted laparoscopic epiphrenic diverticulectomy with esophageal myotomy. Intraoperative findings were consistent with epiphrenic esophageal diverticulum 7.5 × 6.0 × 4.0 cm with severe adhesions to the pericardium and pleura bilaterally. The diverticulum was transected using a stapler, and a myotomy was performed on the opposite side of the diverticulectomy. The patient tolerated the surgery without complication and was discharged home on postoperative day 5. Pathology was consistent with moderate chronic inflammation.

Discussion: The robotic trans hiatal approach offers a safe alternative to the transthoracic approach for the surgical management of epiphrenic diverticula.

Introduction: While vaginal agenesis most often occurs with an absent or rudimentary, nonfunctioning uterus, it may also occur with a fully developed uterine body. In these scenarios, anastomosis of the functional uterus to a neovagina allows for both egress of menstrual blood as well as potential preservation of fertility: case reports exist of spontaneous conception following creation of a neovagina. However, prior attempts at anastomosis have all included delayed surgery with anastomosis to the uterus several months following the creation of the neovagina.

Case description: The patient was a 17-year-old female who presented with amenorrhea several years after thelarche. After noting a blind ending vagina and a 46XX karyotype, ultrasound and MRI revealed an apparently normal uterus with questionable presence of a cervix, and polycystic appearing ovaries, which may have accounted for the patients minimal hematometra. A multidisciplinary team including gynecology, urology, plastic surgery, and colorectal surgery was organized for creation of a neovagina and attempted anastomosis to the normal appearing uterus. In a single staged robotic procedure, a peritoneal neovagina created in a modified Davydov technique was successfully connected to the uterus. A foley catheter was placed in the uterine cavity to allow for canalization. Diagnostic hysteroscopy six weeks after surgery confirmed a canal into the uterus, and the patient reported ongoing cyclical bleeding with the use of oral contraceptives several months after surgery.

Conclusions: In vaginal agenesis with a functional upper reproductive tract, peritoneal neovaginas may be successfully anastomosed to the uterus in a single stage robotic approach.

Introduction: Boerhaave's syndrome, or the spontaneous transmural perforation of the esophagus, is typically thought to be due to an increase in esophageal pressure such as that which occurs during vomiting or retching. Another common etiology of esophageal perforation is esophageal instrumentation, such as during esophagogastroduodenoscopy or transesophageal echocardiography. This life-threatening condition requires prompt diagnosis and treatment to prevent patient demise. While a history of vomiting can aid in diagnosis, this history can be difficult to elicit in an unconscious patient or may be altogether absent. Additionally, Boerhaave's syndrome can present similarly to more common upper gastrointestinal or cardiac conditions. Since mortality increases with delays in diagnosis and treatment, it is imperative that clinicians maintain a high level of suspicion for Boerhaave's syndrome and initiate treatment urgently.

Case description: This report presents a 76-year-old man who presented to the emergency department after a history of several syncopal episodes and was found to be in complete heart block. Two days later, he acutely developed abdominal distention and coffee ground emesis. As the medical team was able to gather more history from the patient and his family, it was revealed that he had associated vomiting with his episodes of syncope. CT scan of the abdomen and pelvis demonstrated pneumomediastinum concerning for esophageal perforation. His clinical status subsequently deteriorated. He was intubated and a temporary transvenous pacer was placed before being transferred to our facility for emergent surgery.

Discussion: Complete heart block in the setting of Boerhaave's syndrome is exceptionally rare, with only 2 cases reported in the literature. The decision to place a pacemaker in the setting of esophageal perforation/sepsis is complicated and depends on the patient's bacteremia status related to noncardiac comorbidities. Clearly this case represents the need for excellent multidisciplinary decision-making processes with excellent communication between hospital staff and all caretakers. Expeditious diagnosis and treatment of esophageal perforation is essential to prevent leaking of gastric contents into the mediastinum and worsening of cardiac complications and sepsis. Additionally, critical timing of various surgical procedures, especially the need for a permanent pacemaker implant with bacteremia is a complicated process not well described in the surgical literature.

Introduction: Performing endoscopic retrograde cholangiopancreatography (ERCP) in duodenal switch (DS) patients is challenging given their surgically altered anatomy. There have been very few reported cases of trans enteric rendezvous ERCP to relieve biliary obstruction in DS patients. More specifically, there has not been any reported cases of this procedure being performed in loop DS, also known as SADI (single anastomosis duodeno-ileostomy) or SIPS (stomach intestinal pylorus sparing procedure).

Case description: This case reports describes a 50-year-old male with prior loop DS who presented with gallstone pancreatitis. He underwent a laparoscopic cholecystectomy with positive intraoperative cholangiogram requiring the need for trans enteric rendezvous ERCP.

Discussion: Although never reported, trans enteric rendezvous ERCP is a feasible approach in relieving biliary obstruction in patients with loop DS anatomy.