Postoperative loss of vision is a serious but under-appreciated complication after surgery. Although more commonly seen with cardiac and spinal surgery, we report a rare case where ischemic optic neuropathy is associated with laparoscopic surgery. An ASA-2 middle-aged man with hypertension and obesity underwent a laparoscopic resection of rectosigmoidal adenocarcinoma. Intraoperatively, no surgical complications were noted with minimal blood loss encountered. He was positioned in a steep Trendelenberg position for 5 continuous hours, and had a mean blood pressure of at least 75 mm Hg throughout. Postoperatively, he had obvious facial and periorbital swelling. Initial decreased visual acuity was noted immediately and this only partially improved over several days and weeks. Magnetic resonance imaging and angiography revealed no structural abnormality and after ophthalmology review, a diagnosis of ischemic optic neuropathy was made. We describe a case showing the association of postoperative loss of vision with laparoscopic surgery and prolonged Trendelenberg positioning.

Hepatoportal arteriovenous fistulae are a rare cause of portal hypertension, which can have significant clinical manifestations. They have multiple etiologies, one of which includes hepatic trauma. We present a case of hepatoportal fistula presenting with bleeding esophageal varices in an 83-year-old man. The exact cause of fistula in this case is not entirely clear; however, hepatic trauma was noted in the patients' history, some 52 years before presentation. We also present a literature review on this rare and interesting phenomenon.

Bladder carcinoma can be treated with cystectomy and urinary diversion. Ileal conduit is a popular technique, originally performed with closure of all mesenteric and peritoneal defects to minimize internal herniation. Recent advances in laparoscopic and robotic techniques often leave these defects open. We present a case of a 75-year-old gentleman with a small bowel entrapment underneath an intraperitoneal ileal conduit and ureter causing obstruction. This internal hernia occurred 2 months after undergoing a DaVinci robotic-assisted laparoscopic cystoprostatectomy with an ileal conduit. Bowel obstruction is an important complication associated with the need for reoperation and patient mortality. Historical review shows a precedent for closure of the mesenteric defect, obliterating the peritoneal defect in the right lumbar gutter, and suturing the ileal conduit to the posterior peritoneum to prevent potential internal hernias. The literature involving ileal conduits is examined for consensus on the preferred method of treating these potential spaces.

Small-intestinal nonmeckelian diverticula are very uncommon and are considered to be acquired pulsion diverticula. Most of these diverticula are asymptomatic and are simply incidental findings. Complicated-acquired diverticular disease of the jejunum and ileum is a diagnostic dilemma. Small-bowel diverticulum is diagnosed with the aid of radiography techniques, such as small-bowel contrast series or enteroclysis. Laparotomy remains the gold standard for a definite diagnosis of asymptomatic and complicated diverticula, but laparoscopy is also very useful in the diagnosis and treatment of this condition. A surgical approach is the best form of treatment for complicated jejunoileal diverticula. The current report is about a patient who presented with iron deficiency anemia caused by a complicated jejunal diverticulum and managed with single-trocar transumbilical laparoscopy.

Anastomotic leakage, although uncommon, is a life-threatening complication and requires prompt recognition and treatment. Surgical closure has been recommended for defects that are large and symptomatic. However, recent reports on successful endoscopic closure of anastomotic leakage suggest that endoscopic techniques may be a feasible alternative to surgical approaches in patients with comorbid conditions that are not suitable for undergoing second operation or for those who refuse to be reoperated. Herein, we describe a case of postoperative gastrojejunal anastomotic leakage that was successfully treated with endoscopic closure using endoclips and detachable snares.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in adults. They frequently occur in the stomach. Gastric GISTs typically present as a gastrointestinal bleed but can sometimes cause obstructive symptoms such as nausea and vomiting. We present a patient with a gastric GIST and liver metastases who during treatment with iminitab therapy presented with an acute gastric outlet obstruction. A computed tomography scan revealed a gastroduodenal intussusception of the gastric GIST. The patient underwent a laparoscopic exploration and resection of the GIST. We reviewed the English language literature of GISTs that presented as a gastroduodenal intussusception and put our case in the context of the previously reported cases. We discuss the diagnostic and therapeutic challenges that arise when treating these patients.

: Upside-down stomach usually is asymptomatic in adults, but sometimes it can cause regurgitation, vomiting, and weight loss. This condition has an incidence increasing with age thus increasing the risk of surgical intervention.: A 90-year-old man was admitted with dysphagia, postprandial regurgitation, and an 18 kg weight loss in the past year. Gastroscopy revealed a significantly dilated, cranky esophagus and an upside-down stomach. The diagnosis was confirmed by a barium swallow and computed tomography. The stomach was repositioned with a gastroscope using insufflation and an α-loop maneuver under fluoroscopic guidance. A percutaneous endoscopic gastrostomy tube was then inserted to fix the stomach. The patient was discharged on the first postinterventional day. He gained 6 kg in the next 2 months.: High-risk patients with upside-down stomach can be managed by endoscopic repositioning of the stomach and percutaneous endoscopic gastrostomy fixation. This is a useful alternative therapeutic intervention. There have been 14 similar cases being reported in the literature.

We report here on a case of intraductal papillary mucinous neoplasm (IPMN) of the bile duct, associated with gallbladder agenesis. A 65-year-old woman was admitted to the hospital with epigastric pain, anorexia, and nausea. Abdominal computed tomography scan and magnetic resonance imaging showed a 5×2.5 cm lobulated cystic lesion in the lateral lobe of the liver. The gallbladder was not seen on both imaging modalities. Endoscopic retrograde cholangiopancreatography suggested the diagnosis of biliary IPMN due to abundant mucin that protruded from the papilla and the lobulated cystic lesion. Laparoscopic wedge resection of the liver was performed. The final pathology was consistent with biliary IPMN. The specimen showed multifocal high-grade dysplasia with negative resection margins. The patient experienced no postoperative complications and was discharged 5 days after the operation.

Laparoscopic distal pancreatectomy (LDP) has entailed ventrally retracting the stomach to afford adequate visualization. The retracted stomach commonly droops over the pancreas and obstructs the surgical field, thus forcing the assistant surgeon to repeatedly lift the stomach out of the way ventrally and cranially. We herein reported LDP using the "lesser curvature approach" in which the pancreas was approached cephalad to the lesser curvature of the stomach in underweight patients with a coincidental low hanging stomach. An excellent view of both the distal pancreas and the spleen could be afforded, enabling complete mobilization of these organs from the retroperitoneum and easy ligation of the splenic vessels, without needing to retract the stomach ventrally and cranially. The lesser curvature approach in LDP could be performed safely and efficiently as an alternative to the conventional greater curvature approach in underweight patients with a low hanging stomach.

: Splenic biopsies are not routinely performed because of the risk of severe hemorrhage. The aim of this study was to explore the feasibility of performing laparoscopic splenic biopsies using a fibrin sealant in pigs and then to translate this technique into the clinical setting.: Four German Landrace pigs underwent a laparoscopic splenic biopsy using a fibrin sealant to occlude the needle tract. Time to achieve hemostasis and postoperative hemorrhage were assessed.: The average time to achieve haemostasis was 15 s (range, 8 to 25 s) with no hemorrhage from the needle tract observed. Subsequently this was translated into the clinical setting where a patient also underwent a laparoscopic splenic biopsy without any adverse effect.: Laparoscopic splenic biopsy with the application of a fibrin sealant is a safe and efficient technique.