SPA (Single Port Access) Cholecystectomy

New - Laparoscopic Repair of Incarcerated Ventral Hernia

Robotic-Assisted Repair of Diaphragmatic Hernia

Laparoscopic Gastric Banding with Autonomy Needle Holder

Laparoscopic Gastric Banding with Autonomy Articulating Needle Holder by Dr. Dmitry Nepomnayshy.

Diagrams for Surgical Procedures of Chronic Pancreatitis

The selection of the operative procedure often depends on the surgeon's expertise and individual preference. There is some criteria that usually favor one type of surgery over another. When the pancreatic duct in the body or tail is dilated beyond 6 mm, the Puestow procedure is usually the most effective surgery . When disease occurs predominantly in the head, Frey's procedure is used. When there is a focal mass in the head without significant duct dilation, the Whipple procedure is most frequently used. Increasingly, Beger's procedure, which preserves the duodenum, is used as an alternative.

1-Whipple Procedure:

The most common pancreatic resection surgery is the Whipple procedure, which is performed for chronic pancreatitis with ductal strictures or amorphous inflammatory mass in the head for which distinction from cancer cannot be made preoperatively. However, many specialist pancreatic surgeons no longer consider this to be the most appropriate surgery for chronic pancreatitis.

Diagram of pylorus-preserving Whipple procedure. Classic Whipple procedure is shown in inset: It entails radical dissection of pancreatic head, adjacent nodes, right half of omentum, gall bladder, common bile duct, and most or all of duodenum followed by gastrojejunostomy/duodenojejunostomy (green arrow), pancreaticojejunostomy (blue arrow), and hepaticojejunostomy (red arrow). (Courtesy of the Office of Visual Media, Indiana University)

2-Beger's Procedure :

Beger's procedure is a less radical surgery with resection of the pancreatic head and preservation of the duodenum . After Beger's surgery, pain relief is seen in up to 85% of patients at 5-year follow-up , but the postoperative morbidity rate is 20%. A randomized study comparing Beger's and Whipple procedures showed similar results at 6 months except for better pain tolerance and glucose control in those treated with Beger's surgery.

Diagram of Beger's procedure. Pancreatic body and most of head have been resected. Sleeve of pancreas is left with duodenum to preserve blood supply for latter. This procedure is technically harder to perform than Whipple procedure. Note pancreaticojejunostomy (red arrows) at two sites of Roux limb (green arrow).

3-Puestow Procedure :

The Puestow procedure is a side-to-side longitudinal pancreaticojejunostomy that drains the pancreatic duct directly into a loop of jejunum . This procedure is best performed if the main pancreatic duct is significantly dilated, usually wider than 6 mm.

Diagram of Puestow procedure. Pancreas is filleted to expose main duct from neck to tail and ductal calculi are removed. Roux loop is anastomosed to "capsule" of pancreas with direct drainage of main and secondary pancreatic ducts into jejunum over 8- to 10-cm segment. Loop (arrows) lies anterior to pancreas.

4-Frey's Procedure :

Frey's procedure is a recently popularized procedure that combines partial resection of the pancreatic head with a longitudinal jejunostomy . The morbidity rate of Frey's procedure is approximately 9-22% , well below that of the Whipple procedure performed for chronic pancreatitis, for which the complication rate is 30-40% . Frey's procedure is contraindicated in the presence of duodenal or biliary stricture.

Diagram of pancreas after Frey's procedure. Head of pancreas is cored out (blue arrow) and pancreaticojejunostomy is created via Roux loop (green arrows). Procedure is best performed in patients with duct dilation of head and body.

Pelvic Spleen

A healthy, 23-year-old, nulliparous woman presented with lower abdominal pain, which she reported having had intermittently for the previous year. She had no other symptoms of gastrointestinal distress. A peripheral-blood smear showed no Howell–Jolly bodies.

Physical examination revealed a palpable mass in the suprapubic region. Abdominal ultrasonography revealed displacement of the spleen from its normal position and a homogeneous soft-tissue mass (measuring 11.0 by 9.3 by 4.2 cm) in the pelvis. Imaging of the liver and spleen after injection of technetium-99m sulfur colloid (Panel A) revealed a normal liver and a well-defined area showing abnormal accumulation of radiotracer (arrow) in the lower abdomen.
Multislice computed tomography, with three-dimensional reconstruction of a coronal image (Panel B), revealed the position of the spleen in the pelvis (black arrow), with torsion of the elongated pedicle (white arrow).

Wandering spleen, or pelvic spleen, is an uncommon condition associated with laxity or malformation of the suspensory ligaments of the spleen. Splenic torsion and infarction are potential complications. The principal therapeutic options are splenopexy and splenectomy. After discussion of treatment options, the patient declined surgical intervention and has continued to do so in follow-up over the past 3 years.

Differential Diagnosis of bile duct dilatation

Whenever there is bile duct dilatation, the first priority is to look for obstruction.




Obstruction
If there is an obstruction, we first look for gallstones in the bile duct. If there are no gallstones involved, we then look for strictures.
The differential diagnosis for a stricture is based on the location.

* A distal stricture is most likely the result of a distal cholangiocarcinoma, pancreatic carcinoma or pancreatitis.
* A stricture within the liver is likely due to gallbladder carcinoma or inflammatory strictures like PSC (Primary Sclerosing Cholangitis) or AIDS cholangiopathy.
* Metastatic disease can occur anywhere within the bilairy system.


No Obstruction
Once we have excluded obstruction, we have to think about nonobstructive biliary diseases like:

* Caroli disease
* Choledochal cyst
* Recurrent pyogenic cholangitis
* Primary sclerosing cholangitis

Appearance of lye strictures in X-ray

-What is the most likely diagnosis in the patient shown below?

a. Esophageal varices
b. Esophageal carcinoma
c. Reflux esophagitis
d. Lye stricture
e. Fibrovascular polyp


THE RIGHT ANSEWR : .d

There is very long segment of smoothly narrowed esophagus from just below the level of the clavicles to the EG junction. This appearance is characteristic ............

Read more...........>>

Ileocecal Intussusception

A 45-year-old man with no notable medical or surgical history presented with a 24-hour history of intense pain in the right side of the abdomen with associated nausea and vomiting. He reported having had similar but much less severe episodes during the previous 6 months. Results of initial laboratory tests were unrevealing.
Physical examination showed moderate abdominal distention. Computed tomographic scans of his abdomen revealed an ileocecal intussusception (Panel A, arrow) with a pathologic mass, 2.5 cm in diameter, at the apex, also known as the lead point (Panel B, arrow). Diagnostic laparoscopy was performed, and the diagnosis of intussusception was confirmed.

Laparoscopically assisted ileocecal resection with primary anastomosis was performed. Gross inspection of the specimen showed a pedunculated lipoma within the terminal ileum. The patient had a rapid recovery, with complete resolution of his symptoms.

Laparoscopic appendectomy surgery.

64 MDCT/CTA/3D Evaluation of Pancreatic Masses

Gastric diverticulum PIC

Upper gastrointestinal endoscopic scan showing a diverticulum (arrow) in the fundus of the stomach.

Gastric diverticula are uncommon.with equal distribution among men and women, and can be congenital or acquired.Areas of weakness caused by splitting of the longitudinal muscle fibres, an absence of peritoneal membrane and perforating arterioles may predispose to the formation of a diverticulum.
Patients with gastric diverticula are often asymptomatic, although they may present with dyspepsia, vomiting and abdominal pain. Complications such as ulceration, perforation, hemorrhage, torsion and malignancy are uncommon. The condition is diagnosed incidentally by radiologic or endoscopic examination. There is no specific treatment required for an asymptomatic diverticulum.
Surgical resection is recommended when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy. Both open and laparoscopic resection yield good results. Perioperative gastroscopy can help locate the diverticulum in difficult situations.
WATCH THE VIDEO

Abscess in Abdominal Wall

An 83-year-old man with hypertension presented with a 3-month history of a painful, progressively enlarging mass in the right subcostal region. He reported no associated constitutional symptoms and no history of abdominal surgery. Local examination revealed a tender, erythematous, fluctuant mass, 3 cm by 2 cm, with clinically significant surrounding induration and an underlying fixed mass (Panel A).

Computed tomography revealed that the mass was communicating with a large gall bladder mass (Panel B, arrow). Ultrasonography-guided needle biopsy, along with histologic and immunocytochemical examinations, confirmed that the mass was an adenocarcinoma of the gall bladder. The patient did not agree to any further evaluation or treatment. He was discharged with plans for palliative care and died 5 weeks later.

SIngle Incision Laparoscopic GastroJejunostomy for an advanced cancer stomach

Pearl necklace sign

Adenomyomatosis of the gallbladder is a hyperplastic cholesterolosis of the gallbladder wall which is common and benign.
Adenomyomatosis presents usually asymptomatic, however in most cases It is associated with chronic biliary inflammation, most commonly gallstones in 25 - 75% but also seen in cholesterolosis in 33% and pancreatitis.

The pearl necklace sign is seen in patients with adenomyomatosis of the gallbladder, on both oral cholecystograms and MRCP. It represents the contrast / fluid filled intramural mucosal diverticula (Rokitansky-Aschoff sinuses) which line up reminiscent of pearls on a necklace.

MRI images demonstrate adenomyomatosis at the gallbladder fundus This case was donated to Radiopaedia.org by Radswiki.net

It is said to be highly specific (92%) for the diagnosis of adenomyomatosis, however is frequently not seen, only present in ~70% of cases.

CT & Sonography of Pancreatic Serous Cystadenoma

Cystic lesions of the pancreas are common, and 80-90% of these lesions are pseudocysts or retention cysts. Cystic neoplasms of the pancreas are less common, accounting for about 10-15% of all cystic pancreatic lesions. True cysts of the pancreas are rare.

The two most common cystic neoplasms of the pancreas are serous cystadenoma (which is benign )and mucinous cystic neoplasms.Serous cystadenoma is more common than mucinous cystic neoplasm, with a ratio of about 2:1. Intraductal papillary mucinous tumor (IPMT) is a more recently discovered cystic neoplasm that may be a variant of the mucinous cystic neoplasm (biologic behavior of mucinous cystic neoplasm and IPMT ranges from benign to malignant).

Radiography:

No radiographic abnormalities are associated with serous cystadenoma except those related to a mass that is large enough to displace or obstruct the bowel or those related to a prominent central calcification.
The main mimics of this tumor are pseudocysts and mucinous cystic tumors.

C.T. : Classically, these lesions have a mean diameter of 5-8 cm (range, 4-20 cm) and a lobulated external contour. They are composed of a grapelike cluster or honeycomb pattern of 6 or more uniformly sized cysts that are 2 cm or smaller. They tend to occur in the head or neck of the gland, although biliary obstruction is present in only about 15% of the cases.

In about 30% of the cases, a central, stellate, late-enhancing scar is present with calcification. Small septa and internal debris may be seen in individual cysts. Because the capsule of these tumors is poorly developed, there is often poor distinction of the tumor from the surrounding pancreatic parenchyma. No communication occurs with the pancreatic duct, except in rare cases.

Serous cystadenoma on a contrast-enhanced CT scan. Note the Swiss cheese–like enhancement and gentle external lobulation.

Serous cystadenoma on a nonenhanced CT scan. Note the central calcification, attenuation similar to that of water, and external lobulation.

Ultrasonography:

The cluster-of-grapes pattern and external lobulation may be seen. However, when the cysts are small, the mass can be echogenic (because of the large number of acoustic interfaces), and they can appear solid (see the image below). This finding can suggest the presence of an adenocarcinoma. The presence of increased through transmission, even if the mass is fairly echogenic, should suggest the diagnosis.

Sonogram of serous cystadenoma. The large mass in the head of the pancreas is externally lobulated, with some cystic-appearing regions, some solid-appearing regions, and increased through transmission. Image courtesy of Arnold C Friedman, MD, FACR.

The Liver Injury Scale (LIS) classification

The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury . Damage to the liver is the most common of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle crashes (MVC)

Hepatic injury was graded according to the Hepatic Injury Scale established by the American Association for the Surgery of Trauma (AAST).

This is a liver injury . The injury has been opened to control bleeding branches of the portal and hepatic veins as well as the hepatic arterial radicles. Several biliary ducts were ligated.

Grade and Description of injury

 Grade I : *Haematoma--->Subcapsular, non-expanding, less than 10 percent of surface area
*Laceration--->Capsular tear, non-bleeding, parenchymal depth less than 1 cm

Grade II : *Haematoma--->Subcapsular, non-expanding, 10–50 per cent of surface area or intraparenchymal, non-expanding, less than 2 cm in diameter.
*Laceration--->Capsular tear, active bleeding, parenchymal depth 1–3 cm, less than 10 cm in length.

Grade III : *Haematoma--->Subcapsular, more than 50 per cent of surface area or expanding ruptured subcapsular haematoma with active bleeding intraparenchymal haematoma larger than 2 cm.
*Laceration--->Parenchymal depth more than 3 cm.

Grade VI : *Haematoma--->Ruptured intraparenchymal haematoma with active bleeding.
*Laceration--->Parenchymal disruption of more than 25–50 percent of hepatic lobe.

Grade V : *Laceration--->Parenchymal disruption of more than 50 per cent of hepatic lobe.
*Vascular--->Juxtahepatic venous injuries.

Grade VI : *Vascular--->Hepatic avulsion.

Alvarado Score In Appendicitis

Mnemonic for Causes of Pancreatitis

A common mnemonic for causes of Pancreatitis " I GET SMASHED ",an allusion to heavy drinking(one of the many causes)


-I: idiopathic
-G: gallstone; Gallstones that travel down the common bile duct and which subsequenly get stuck in the Ampulla of Vater .................

Read more............>>

USMLE ALGORITHMS: Upper GI Bleeding

This Video Algorithm is going to discuss Upper GI Bleeding. Topics included:

- Mallory Weiss
- Boerhaave's Syndrome
- Esophageal Varices

We will be discussing the presentation of Upper GI bleeding, as well as the full management.