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Abdominal trauma
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Steven Stylianos, Mark V. Mazziotti
Laparoscopic distal pancreatectomy is often performed with four trocars. A hand-assist port can be useful in some settings, but use may be limited in younger children with less abdominal domain. Subcostal and perixiphoid trocar positions are modified according to the size of the child. Working ports should accept 5 mm instruments and at least one port should accept endosurgical stapling devices. After achieving pneumoperitoneum, the lesser sac is entered through the gastrocolic ligament and omentum. The pancreas is then explored through the lesser sac. If the spleen is to be preserved, the short gastric vessels are preserved. To gain further exposure of the pancreas, the short gastric vessels can be taken up to the level of the gastroesophageal junction, but splenectomy will then be required. The splenic flexure is then mobilized to expose the inferior edge of the tail of the pancreas. The pancreas is mobilized out of the retroperitoneum by incising the peritoneum from the inferior edge of the pancreas to the inferior pole of the spleen. The pancreatic tail can then be mobilized and retracted medially. This dissection allows the splenic artery and vein to be isolated and divided with a vascular stapler or between clips.
Hand-Assisted Laparoscopic Colorectal Surgery
Published in Haribhakti Sanjiv, Laparoscopic Colorectal Surgery, 2020
Deeksha Kapoor, Amanjeet Singh, Adarsh Chaudhary
Splenic flexure mobilization: All sigmoid or anterior resections may not warrant splenic flexure mobilization. To mobilize the splenic flexure, the surgeon stands between the legs of the patient and inserts an additional 5-mm port on the left side. The transverse colon is pulled caudally and the avascular plane between the colon and gastrocolic omentum incised. After entering the lesser sac, the surgeon palpates the avascular plane between the omentum and colonic mesentery, incising it with a harmonic scalpel. Once this is complete, the only attachment remaining is the lienocolic ligament. With the colon in the left hand and medial traction, the glistening lienocolic ligament is divided and the splenic flexure reflected down. At this point, the inferior aspect of the tail of the pancreas may be identified in the lesser sac.
Diseases of the Hepatobiliary Tree and Pancreas Associated with Fever
Published in Benedict Isaac, Serge Kernbaum, Michael Burke, Unexplained Fever, 2019
Pancreatic abscess is usually a complication of pancreatitis or pseudocyst;232 rare causes include tuberculosis,233 and penetration of a peptic ulcer or duodenal diverticulum.234 The symptoms and signs are frequently nonspecific, and diagnosis is often difficult. The presence of moderate or spiking fever, accompanied by anorexia, weight loss, and abdominal (especially epigastric) tenderness, following pancreatitis (acute or chronic), abdominal trauma or biliary tract surgery should raise the clinician’s suspicion of this potentially life-threatening condition. CT scan may reveal gas within the pancreatic bed. Ultrasonography may disclose fluid-filled cavities with numerous internal echoes in the lesser sac. In all cases of suspected pancreatic abscess, radiologically guided percutaneous drainage is mandatory.235
Surgical Management of Life Threatening Bleeding after Endoscopic Cystogastrostomy
Published in Journal of Investigative Surgery, 2018
Ashish George, Rajesh Panwar, Sujoy Pal
The abdomen was explored through an upper midline laparotomy. There was no blood in the peritoneal cavity. The gastrocolic ligament was thickened and there was no avascular plane between stomach and transverse colon. The stomach was pushed anteriorly by the large lesser sac collection. A 6–7 cm anterior gastrotomy was done after taking stay sutures (Figure 2a). The stent was visible after the anterior gastrotomy and there was a bulge in the posterior wall of stomach (Figure 2b). The lesser sac collection was entered through the posterior wall of stomach and a 6 cm cystogastrostomy was done using a 75 mm stapler (Figure 2c). The pseudocyst was filled with around 600 ml of blood clots and there was fresh blood as well. The cyst cavity was quickly evacuated after which the active spurt from the splenic artery was seen. The bleeding was first temporarily controlled using digital pressure. The splenic artery was then ligated in continuity just proximal and distal to the site of bleeding and hemostasis was secured (Figure 2d). The anterior gastrotomy was then repaired in two layers.
Different laparoscopic treatment modalities for splenic artery aneurysms: about 3 cases with review of the literature
Published in Acta Chirurgica Belgica, 2018
Haydar A. Nasser, Alaa H. Kansoun, Youssef A. Sleiman, Vanessa Marron Mendes, Etienne Van Vyve, Antoine Kachi, Tarek Berjawi, Wajdi S. Hamdan, Issam El Nakadi
A 56-year-old female, G2P2, smoker, known to have cerebral vascular accident on anticoagulant, dyslipidemia and diabetes mellitus type 2, was referred to general surgery team because of 1-year history of nonspecific abdominal pain that was refractory to pain killers. When encountered, the patient denied any weight loss, dysphagia, fever or night sweats. Physical examination was not yielding. An abdominal ultrasound revealed 3 SAA. An angioscan confirmed the presence of the three aneurysms respectively at: the origin of the splenic artery (0.4 cm), the middle portion (1.8 cm) and at the splenic hilum (0.5 cm) (Figure 1). Since the patient was on chronic anticoagulation, and since one aneurysm was affecting the hilum, Laparoscopic ligation of the splenic artery (SA) combined with splenectomy was indicated. After appropriate perioperative preparation, the procedure was done under general anesthesia, with patient being positioned in the right lateral decubitus. Five trocars were inserted: 10 mm trocar (para-umbilical as camera port), 12 mm trocar on the left anterior axillary line, 10 cm away from the camera port. Three further trocars, 5 mm each, were inserted for retraction. After entering the lesser sac, the SA was dissected along the superior border of the pancreas. Three aneurysms were identified, the distal one (S1) was the largest (Figure 2). Vascular cutting Endo-GIA staplers were applied to both the SA and the splenic vein. The artery that was dissected along the superior border of the pancreas was removed en bloc analog with the spleen. The patient had an uneventful postoperative course and was discharged on day 2 postoperative. The patient was seen 2 weeks after the procedure and had no complaints. A CT-scan of the abdominal cavity was performed 3 months later and showed no pancreatic abnormalities.
Internal herniation through the foramen of Winslow: a case report
Published in Acta Chirurgica Belgica, 2020
Yanina Jeanne Leona Jansen, Koenraad Nieboer, Ellie Senesael, Kobe Van Bael, Mathias Allaeys
On contrast-enhanced CT scans, a dilated right colon coursing posteriorly to the hepatoduodenal ligament combined with a lateral displacement of the stomach is described as typical for the diagnosis of herniation through the foramen of Winslow. Any intestinal loops in the lesser sac are indicative for this diagnosis. There can be anterior and lateral displacement of the stomach and stretching of the mesenteric vessels through the foramen of Winslow.