Procedure Videos

Procedures:

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Laparoscopy in trauma

Laparoscopy in penetrating abdominal trauma

Laparoscopy in pelvic endometriosis

Laparoscopic recurrent incisional hernia repair

Laparoscopic incisional hernia

Laparoscopic appendicectomy

Laparoscopic appendicectomy for peritonitis

Lap repair of perforated peptic ulcer

Lap treatment of mesenteric cyst

Lap splenectomy for cyst

Laparoscopy in trauma

32 yo woman admitted to the ED after road traffic accident. She was unrestrained passenger in a car which collided with a tree at high speed. Driver of the car in poor conditions due to head, chest and pelvic trauma, transferred to tertiary trauma center directly from the scene. Patient was alert and responsive at her arrival. She was on a long spine board, with two large bore cannulas but no oxygen mask.

Airways: patent and stable. Trachea in central position. C-Spine blocked with collar. No cervical pain.

Breathing: normal and bilateral breathing sounds, SaO2 96%. Pain at lower right ribs.

Circulation: no external bleeding, HR 120. BP 90/50. Abdomen: diffuse tenderness with guarding and rebound. Pelvis stable. Rectal tone normal. Perineal bruising. Vaginal examination normal, tenderness on the right side.

Disability: neuro examination normal. GCS 15.

Exposure: no evidence of penetrating injuries. No tenderness over the spine.

E-FAST-scan: free fluid in the splenorenal pouch, in the hepatorenal pouch and in the pelvis. No fluid in the pericardium. Small quantity of fluid in the right pleural space. No fluid in the left pleural space. No evidence of pneumothorax.

After 1 liter of fluids and oxygen through face mask: PA 110/80. HR 100. SaO2 100%.

After 2 liters of fluids: PA 110/80. HR 85. SaO2 100%.

Chest X-ray: negative.

Pelvic X-ray: fracture of the right inferior pubic ramus.

C-spine X-ray: normal

Blood tests: Hb 95 g/dl.

CT scan: Free fluid in the abdomen. No free air. No evidence of abdominal parenchymal injury. Fracture of the arch of the 7th and 8th right rib. Minimal pleural effusion on the right side.  Non displaced fracture of the right inferior pubic ramus with pelvic and perineal haematoma.

Impression: pelvic fracture with intraabdominal injury

Indication to diagnostic laparoscopy to rule out intraabdominal injuries and active bleeding.

Outcome: pelvic fracture with pelvic haematoma, minimal intraperitoneal bleeding from liver superficial injuries. Conservative treatment. No complications.

Laparoscopy in penetrating abdominal trauma

23 yo man admitted in the ED after being stabbed at his right flank. Patient was alert and responsive at his arrival. Unrestrained on a long spine board.

Airways: patent and stable. Trachea in central position. No cervical collar. No cervical pain.

Breathing: normal and bilateral breathing sounds, SaO2 100%. No chest pain. No respiratory distress.

Circulation: clothes stained with blood, blood on the long spine board. Three centimeters bleeding wound at its right flank. HR 125. BP 110/85. Abdomen: diffuse tenderness with guarding and rebound. Pelvis stable. Rectal tone normal. Prostate normal. No perineal bruising. No bleeding from the urethra.

Disability: neuro examination normal. GCS 15.

Exposure: no evidence of other penetrating injuries. No tenderness over the spine.

E-FAST-scan: free fluid in the splenorenal pouch, in the hepatorenal pouch and in the pelvis. No fluid in the pericardium and in the pleural spaces. No evidence of pneumothorax.

After 1 liter of fluids and oxygen through face mask: PA 120/90. HR 90. SaO2 100%.

Examination of the wound: not sure evidence of direct penetration into the peritoneum.

Chest X-ray: negative.

Blood tests: Hb 128 g/dl.

Diagnostic Peritoneal Lavage: 5 ml of free blood aspirated. No evidence of enteric content.

Impression: penetrating abdominal injury with intraperitoneal bleeding.

Indication to diagnostic laparoscopy to rule out visceral injuries and active bleeding.

Outcome: penetrating abdominal wound with transverse track within the abdominal wall from the right flank to the right upper quadrant, small serosal tear of the small bowel repaired with intracorporeal stitch, no active bleeding. No postoperative complications. Discharged on postoperative day 3.

Laparoscopy in pelvic endometriosis

28 yo woman admitted through ED for acute pelvic pain. History of dysmenorrhea. No previous pregnancies. No other past medical history. No medications.

Abdomen tender, with guarding and rebound in the right and left iliac fossae. Vaginal examination: pelvic tenderness.

Blood tests: Hb 108 g/dl. WBC 11500. CRP 1.2. Pregnancy test negative.

US scan: free fluid in the pelvis, left ovarian cyst with hypoechoic content, appendix not seen.

Indication for diagnostic laparoscopy: acute pelvic pain with raised inflammatory markers. Acute appendicitis. Gynaecological issues.

Outcome: laparoscopic excision of left ovarian endometriosic cyst. Referred to the gynaecologists for medical treatment of her endometriosis.

Laparoscopic recurrent incisional hernia repair

44 yo man referred for recurrent non reducible hernia on umbilical port site.

Laparoscopic spermatic veins closure for bilateral varicocele 8 years before. Open mesh repair of port site hernia 3 years before.

Other past medical history not relevant.

Physical examination: non-reducible and mildly painful recurrent umbilical port-site hernia.

Outcome: laparoscopic repair of recurrent port-site hernia with excision of previous mesh. No postoperative complications. Same day discharge. Followup after 2 years: no recurrence.

Laparoscopic incisional hernia

68 yo man referred for incisional hernia. Accountant. Hobby: gardening and olive harvesting.

Open cholecystectomy for gallstones through transverse right subcostal laparotomy 18 years before.

Past medical history: hypertension and mild chronic obstructive/restrictive pulmonary disease.

Physical examination: Reducible lump on the medial side of the laparotomy scar, gradually enlarging and limiting his physical activities.

Outcome: Laparoscopic incisional hernia repair with mesh. No postoperative complications. Discharge in day 1. Postoperative followup at 6 months: no recurrence.

Laparoscopic appendicectomy

18 yo boy admitted through ED for right iliac fossa pain and vomiting.

Past medical history not relevant.

Abdomen: tenderness with guarding and rebound in the right iliac fossa

Blood tests: WBC 12500. CRP 1.5.

US scan: no free fluid, appendix not seen.

Working diagnosis: acute appendicitis

Outcome: laparoscopic appendicectomy. No postoperative complications. Drainage removed in day 1. Discharge in day 2.

Laparoscopic appendicectomy for peritonitis

32 yo woman admitted through ED for acute abdominal and pelvic pain, with nausea, vomiting and fever in the last 2 days.

Past medical history not relevant.

Abdomen: diffuse tenderness, guarding in the right and left iliac fossae with rebound.

Blood tests: WBC 23000. CRP 11.4. Pregnancy test negative.

US scan: free fluid in the pelvis, in the right iliac fossa and around the liver; enlarged and thick-walled appendix seen in the lower right iliac fossa.

Indication for emergency diagnostic laparoscopy: acute appendicitis

Outcome: laparoscopic appendicectomy. No postoperative complications. Drainage removed on day2. Discharge on day 2.

Lap repair of perforated peptic ulcer

42 yo man admitted from ED for acute stabbing abdominal pain. History of recurrent epigastric pain. PPI treatment was prescribed by his GP several times but he never comply with GP’s suggestions. History of occasional social alcohol abuse and smoking.

Abdomen diffusely guarding and acutely tender. No bowel sounds.

Chest X-ray: left subdiaphragmatic air

Blood tests: WBC 2180. CRP 23.2.

US scan: free fluid in all abdominal quadrants.

Indication to laparoscopy:  acute abdomen with suspected perforation

Outcome: laparoscopic repair of perforated peptic ulcer of the gastric antrum. No postoperative complications. Drainage removed on day 3. Discharge on day 5. Patient lost to followup.

Lap treatment of mesenteric cyst

58 yo man referred for chronic abdominal pain  and palpable mass in his right iliac fossa

No change in bowel habits, no PR bleeding, no weight loss. No other symptoms

No family history of bowel cancer

Physical examination: palpable mass in the right iliac fossa Digital rectal examination negative

US, CT, MRI – 14x12x9 cm thickwalled mesenteric cyst

Blood tests and serology negative

Indication to operation: mesenteric cyst, probably chylous

Outcome: drain out on day 1, discharge on day 3. No postoperative complications. Follow up at 12 months: no recurrence, no symptoms

Lap splenectomy for cyst

27 yo woman referred for dyspepsia and epigastric discomfort for 1 year. No heartburn, no acid reflux, no angina-like chest pain, no abdominal pain, no difficulty in swallowing, no vomiting, no nausea, no haematemesis, no maelena. No change in bowel habit, no PR bleeding. No family history of cancer.

History of insulin-dependent diabetes mellitus.

US/CT – 12 cm non parasitic splenic cyst with thick content

Blood tests normal

Indication for splenectomy: symptomatic large splenic cyst.

Outcome: drain out on postoperative day 1, discharge on postoperative day 2.  No postoperative complications. Followup at 12 months: patient is symptom-free.

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