BACKGROUND Cholecystoduodenal fistula (CD) is a rare complication of gallstone disease. Laparoscopic stapling techniques have been reported as feasible methods for treating this fistula, however these procedures are not always performed successfully. We have reported five cases of CD diagnosed intraoperatively, managed successfully by laparoscopic approach. MATERIALS AND METHODS During the 3-year period, from 2007 to 2009, 1500 patients underwent LC for gallstone desease, five of them (3.3%), who presented with classic symptoms of symptomatic cholelithiasis, intraoperatively CD were found. Data were collected on patients' age, sex, pre-operative diagnoses, operative methods, morbidity and management. Laparoscopic surgery was performed using the standard three trocars technique. RESULTS All patients were females, 67 years old on average. They had gallstones detected by abdominal ultrasound, but CD's were found during operative treatment of gallstones. In three cases CD was completely mobilized with a combination of blunt and sharp dissection and divided using the endoscopic linear stapling device. In the other two cases after division of the cystic duct and artery the gallbladder was dissected from the liver bed, leaving just the fistulous connection to the duodenum. Then division of the fistula was completed using the same stapling device. All five patients had uneventful postoperative course. The hospital stay of five patients ranged from 5 do 10 days (median 6 days). CONCLUSION CD does not preclude a laparoscopic approach. With more experience and improved techniques, most of these cases could be performed laparoscopically, with all of the advan-tages of minimally invasive surgery.

Most of the foreign bodies which enter oesophagus will pass through it freely, while 10-20% of them in most cases remain in physiological and pathological narrowings what requires an intervention. These patients are urgently sent to departments of otolaryngology, gastroenterology, thoracic surgery and general surgery. In adults the most common foreign body is a bone or a lump of meat. Different techniques for extraction of foreign body from oesophagus have already been described: rigid and flexible endoscopy, by Foley catheter, and most recent method of laparoscopic surgery. In our study, we have shown a case where we performed an extraction of foreign body from distal oesophagus by combining endoscopic and laparoscopic method, after an unsuccessful attempt of extraction of foreign body by only endoscopic methods.

Diaphragm injuries are diagnosed in the acute phase of blunt trauma only in 10% of cases--more often they are presented as hernia. Traumatic diaphragmatic hernia presents unique obstacles to a minimal invasive approach. However, with the proper training and equipment, most of these hernias are amenable to laparoscopic approach. These patients can expect the same well-known benefits of laparoscopic approach. We report here the case of a 56-year-old man, admitted to hospital with symptoms of vomiting, abdominal pain and dispnea who sustained blunt abdominal trauma in a high speed motor vehicle accident nine months ago. X-ray and CT scans confirmed suspected strangulated diaphragmatic hernia which contained stomach, colon, majoromentum and spleen in left hemithorax. The urgent laparoscopic procedure was performed--omentum, colon and stomach were taken backthrough diaphragmatic defect but the spleen was tightly fixed in thoracal cavity and splenectomy was performed. The diaphragmatic defect was repaired with interruptured sutures. This case proves that laparoscopic repair of diaphragmatic hernia is effective, but this should be carried out with caution, sometimes it needs additional complex procedure in emergency setting like splenectomy in this case.

There are increasing reports about laparoscopic splenectomy being performed even in blunt trauma patients, especially when conservative treatment has failed, but there are very rare reports involving pregnant patients operated laparoscopically due to a blunt trauma. The fear of possible injury of the fetus and effects on the course of the pregnancy limited the use of laparoscopic surgery in pregnant trauma patients. We report here a case of the laparoscopic splenectomy performed in a pregnant patient who sustained a blunt abdominal trauma, with grade V splenic injury. After diagnostic laparoscopy, which revealed the presence of a large amount of free fluid in the abdomen and a lesion on hilum of the spleen, laparoscopic splenectomy was performed with vascular staple. The patient had an uneventful recovery and was discharged with no discernible effects on the course of the pregnancy. This case shows that laparoscopic splenectomy is feasible and a safe procedure in pregnant patients who sustained a blunt abdominal trauma, but it requires adequate experience in elective laparoscopic surgery of spleen, continuous monitoring of fetal vitality is required.

UNLABELLED In 10-15% of the patients that underwent cholecystectomy, common bile duct stones were found either during the preoperative, intraoperative or postoperative evaluation. Their treatment traditionally was based on open approach and extraction of calculi, with development of endoscopic procedures we have ERCP with endoscopic sphincterotomy, but due to rapid development of laparoscopic procedures now-days we have other therapeutic options such as laparoscopic transcystic extraction and laparoscopic choledohotomy. METHODS During the period between 2007-2009 we treated 168 patients with common bile duct stones. Age range was 21-78 years, 105 female and 63 male patients. We have performed 47 open explorations, 9 laparoscopic transcystic exploration, as well as 112 ERCP and ES. We monitored the rate of success (%), intra- and postoperative complications. RESULTS The success rate of the cases of open exploration was 95%, in 2 cases postoperative cholangiogram showed concrement residues that were successfully treated later on with ERCP+ES. Out of 9 transcystic LCBDE we have performed, in 4 cases extraction was successful, 3 patients underwent conversion into open exploration, and 2 patients were successfully treated with postoperative ERCP. A total of 69 patients were treated with ERCP and ES with the 82% success rate of stone extraction. CONCLUSION Even though laparoscopic and endoscopic procedures have revolutionized treatment of common bile duct stones, the role of ERCP is not changed. Treatment in general hospital settings largely depends on availability of endoscopic and laparoscopic equipment and expertise, and must be individualized according to methods that are available. In our settings we have found that best summary of these demands are achieved by ERCP and laparoscopic approach.

Background: Patients with perforative peritonitis are among the most complex cases encountered in surgical practice. Early prognostic evaluation of these patients is desirable in order to make the correct therapeutic plan, selecting highly risky patients for less aggressive surgical procedures. Prospective evaluation of different prognostic scoring systems was performed in order to assess the possibility of prediction of outcome in these patients. Patients and methods: The prospective study of 145 patients with perforative peritonitis was performed. The main outcome of this study was peritonitis-related death. Variables necessary for calculation of the scoring systems were recorded at the initial admission to the hospital (during the first 24 hours) and the third and seventh day of hospitalization, except Mannheim Peritonitis Index, which was calculated during the first 24 hours after hospitalization, i.e. during laparatomy. Sensitivity and specificity are graphically shown for the different values of cut-off points. Results: ROC curve for TISS -28 and APACHE II is significantly more accurate in comparison with other scores. The area under the curve for the first postoperative day was 0.87 for TISS-28 score, 0.86 for APACHE II score, 0.83 for MOF, 0.83 for SAPS I, 0.72 for MPI score, 0.70 for Sepsis score. In addition, this discriminatory ability remained on the third and seventh postoperative day as well. The highest rate of correlation between the observed and the expected mortality rate was in APACHE II system, for the first (Kendall’s τ correlation 0.964) and the third (Kendall’s τ correlation 0.8l0) day. There was a decrease in the rate of correlation on the seventh day for all scoring systems except for MOF score. Conclusion: APACHE II is better in prediction of the outcome to other tested scoring systems.

Acute appendicitis is one of the most common causes of acute lower abdominal pain. However, there are other diseases that can cause pain and mimic acute appendicitis. Some of these conditions are treated surgically; however, some of them should be treated conservatively. Therefore, the treatment of diseases associated with a number of decisions made by doctors and patients. The decision making is divided into three levels. At the first level, the patient and his family are to decide that patient should go to visit physician. At the second level is a physician in primary health care, who decides whether a patient deserves conservative or operative treatment. If he think that it is necessary to forward patient to the hospital, the other specialist: surgeons, urologists and gastroenterologists are involved in the decision making process. At the third level are decisions about the future treatment of the patient. The patient can be sent to home treatment, control exam could be appointed, patient cold be operated or observed. For decision making process physicians use information collected from patient’s history, physical examination of patients, laboratory tests and radiological examinations.

BACKGROUND Laparoscopic appendectomy (LA) has many advantages over the classic appendectomy (CA), but this method has not been accepted yet in Bosnia and Herzegovina. Therefore, we attempted controlled randomized study in order to compare classic appendectomy with laparoscopic appendectomy and confirm eventual advantages of caring base of appendix with hem-o-lok clips regarding ordinary accepted endoloop method during laparoscopic appendectomy. METHODS In this prospective study 120 patients were involved which are divided into two groups. In group 1, 60 patients were operated with classic method, and group II was divided into two subgroups; 30 patients were operated with laparoscopic method in which the base of appendix was cared by double endo-loop method and 30 patients were operated by plastic non-resorptive hem-o-lok clip. During this study the time duration of operation was measured, the duration of application of hem-o-lok and endo-loop, postoperative analgesia, the duration of hospitalization, intra-operative complications, anatomic position of appendix, appendicitis, and postoperative complications. RESULTS The results of the study showed that laparoscopic appendectomy is shorter in duration if compared to the classical appendectomy with statistical significance p < 0.001 (CA 69,4 min; LAH 36,6 min; LAE 37,1 min), hospitalization is shorter p < 0.0001 (CA 3,6 days; LAH 2,3 days; LAE 2,2 days). Quantity of given analgesics in LA is less than in CA without statistical significance between LAE and CA (p > 0.340) and between LAE and LAH (p > 0.148) while there is positive statistical significance between LAH and CA (p < 0.015). Precise period of cicatrization of wound of patients operated by CA was 43 (71.66%) cases, with infection of wound in 3(5%) cases, phlegm of wound in 2 (3.3%) cases, healing of wound per sekundam in 9 (15%) cases and ileus in one (1.6%) patient. One patient had an infection of umbilical wound in LA and the other had cellulitis of front abdominal wall. Duration of application of hem-o-lok is shorter compared to endo-loop with statistical significance p < 0.013 (LAH 68,2 s; LAE 176,9 s). CONCLUSION Time of surgery is shorter and the duration of hospitalization, amount of given analgesic is smaller, less number of postoperative complications, better cosmetic effect and advantages of application of hem-o-lok over endo-loop laparoscopic appendectomy is preferred.

During the laparoscopic appendectomy, the base of appendix is usually secured by double endoloop ligatures or by stapler. In this article we will show our initial experience in securing the base of appendix by plastic XL hem-o-lok clip during laparoscopic appendectomy. Patient, 24 years old with acute appendicitis is admitted to the Department of Surgery. After dissection of mesoappendix and appendicular artery by ultrasonic dissector, two hem-o-lok clips are placed on the base of appendix, and another clip is placed on distal part, which will be removed. Application of clip is made by hem-o-lok XL endoscopic applier.

Laparoscopic splenectomy is accepted as a gold standard in the treatment of different hematologic diseases, but there are only sporadic reports about its use in the trauma patients. We report here the case of the urgent laparoscopic splenectomy performed in pregnant patient who sustained blunt abdominal trauma, with grade V of splenic injury. In the position of supination, diagnostic laparoscopy revealed the presence of a large amount of free fluid in the abdomen, and a lesion onhilum of spleen. After mobilization of the spleen, en masse transection of the splenic pedicle was done with vascular stapler, and the spleen was removed by endobag through the expanding one of the ports. Patient had an uneventful recovery and was discharged on the eight postoperative day, with no discernible effects on the course of the pregnancy. This case shows that laparoscopic splenectomy in ruptured spleen is feasible and a safe procedure, even in pregnant patients who sustained a blunt abdominal trauma, but it requires adequate experience in laparoscopic surgery and elective laparoscopic splenectomy.

BACKGROUND Simplification of APACHE II scoring system in the prediction of the outcome in critically ill patients with perforative peritonitis can be a useful and a cheaper model than the standard APACHE II system. We tested APACHE II and SAPS I scoring systems and variables of arterial pH, pO2, pCO2 and HCO3, cholesterol and albumin in the prediction of the outcome in these patients. PATIENTS AND METHODS The prospective study involved 145 patients of both sexes with perforative peritonitis. The main outcome of this study was peritonitis-related death. APACHE II and SAPS I scoring systems were calculated on the admission (during the first 24 hours). Cutoff points were specified and all values greater than the cut-off points were taken to predict death. Sensitivity and specificity are graphically shown for the different values of cut-off points. They are presented with the ROC curve. Variables of arterial pH, pO2, pCO2 and HCO3 were tested with Feed-Forward Artificial Neural Network which had 4 hidden layers with 8 neurons in the layer. We used Levenberg-Marquardt method for training, and 16 variables for the entrance in the network. We tested correlation between cholesterol and albumin levels with the patient outcome. RESULTS APACHE II ROC curve demonstrated that its discriminatory ability was better than the SAPS ROC curve. The area under the curve was 0.86 for APACHE II score in comparison to 0.83 for SAPS score. This illustrated that APACHE II is significantly better (P < 0.01) at determining of outcome. Use of FeedForward Artificial Neural Network (ANN) for analysis of variables such as arterial pH, pO2, pCO2 and HCO3, showed that withdrawal of these variables lead to the decreased power of prediction of APACHE II scoring system. Measurement of the correlation between the cholesterol and albumin levels and the patient outcome revealed that there was no significance between these parameters, as the level of correlation for cholesterol and albumin was -, 1, and -, 14, respectively. CONCLUSION APACHE II has better prognostic power than SAPS scoring system. Withdrawal of variables such as arterial pH, pO2, pCO2 and HCO3, reduces the prognostic power of APACHE II system.

BACKGROUND Laparoscopic appendectomy (LA) has recently become a standard procedure in the treatment of acute appendicitis, as it has been shown to be advantageous over open appendectomy. Since laparoscopic appendectomy was recently introduced in Bosnia and Herzegovina, we evaluated the practice of this procedure in the treatment of acute appendicitis. METHODS An audit was carried out through a written questionnaire sent to 16 different medical hospitals in Bosnia and Herzegovina. The questionnaire examined the use of laparoscopic appendectomy since the period of its introduction to the end of 2007, including operative time, hospital stay, morbidity and mortality rates, conversion rate and the reasons for the conversion and laparoscopic technique. RESULTS The response rate from the questionnaire was 37.5%, but only three institutions (18.75%) perform LA. The mean interval from introduction of laparoscopic surgery to inception of LA was 5 years. In period from inception of LA to the end of 2007, 243 appendectomies were done by laparoscopic approach. Correct diagnosis were made in 229/243 cases. Mean hospital stay was 2.2 +/- 0.4 days. Postoperative complications were observed in 13/243 patients. The most frequent complications were intrabdominal abscess (4/13), wound infection (4/13) and intrabdominal bleeding (2/13). Nine conversions from LA into open procedure were done, two due to technical reasons (equipment malfunction), two due to mesoappendix bleeding and five due to periapendicular block or retrocecal position. Conversions and postoperative complications were observed only at the start of the introduction of this procedure. CONCLUSION Only three institutions in Bosnia and Herzegovina, with small surgical teams, routinely perform laparoscopic appendectomy. Thus, there is a need for systemic education of surgical teams across the country. Laparoscopic appendectomy could be the first operation in the acquisition of laparoscopic skills.

Introduction: Laparoscopic appendectomy becomes a usual method in the treatment of acute appendicitis, although its advantage over open appendectomy has been proven. In Bosnia and Herzegovina, a few medical centers are introducing laparoscopic appendectomy as a method of treatment of acute appendicitis. In this study we want to compare different methods of treatment of acute appendicitis. Patients and Methods: During 20 months we have analyzed 498 patients operated due to acute appendicitis. We followed the duration of operation, total hospitalization stay, complications of surgical procedure and reasons of conversion in patients operated by laparoscopic approach. Results: The duration of operation was 96 minutes in the group operated by open approach and 107 minutes in the group operated by laparoscopic approach. Total hospitalization stay was 3.9. days in the group operated by open approach and 2.3. days in the group operated by laparoscopic approach. The most frequent complication in the group operated by open approach was infection of the operative wound (56/452) and ileus (5/452), and in the group operated by laparosocopic approach ileus (1/46) was the most frequent complication. Conclusion: The patients operated by laparoscopic approach have fewer risk of wound infection, and the hospital stay is shorter. With the increase of surgeon’s experience this method of treatment of acute appendicitis will become a method of choice.

Aim. The aim of the present paper is to compare the use ofArtificial Neural Network (ANN) to APACHE II, MOF, TISS-28 and MPI scoring system in prediction of peritonitis-relateddeath in patients with perforative peritonitis. Patients andmethods. A prospective study was performed of 145 patientswith perforative peritonitis, treated in the Surgical IntensiveCare Unit. The main outcome of this study was peritonitisrelateddeath. The Levenberg-Marquardt method was usedfor training, and 16 variables for entrance into the ArtificialNeural Network. Sensitivity and specificity of scoring systemsare graphically shown for the different values of cut-off pointswith the receiver-operating characteristic curve (ROC) curve.Results. We tested 92 cases in a network and found that theAPACHE II system predicted the lowest number of wrongassessments with a score of 12, with all the other scoringsystems predicting 19 wrong assessments. The area underthe curve for the first postoperative day was 0.87 for TISS-28score, 0.86 for APACHE II score, 0.83 for MOF and 0.72 forMPI score. The highest rate of correlation between the observedand the expected mortality rate was in the APACHEII system. This demonstrated that TISS-28 and APACHE IIare significantly better than other systems (P<0.01). In addition,this discriminatory ability was also retained on the thirdand seventh postoperative days. Conclusion. APACHE II issuperior in the prediction of patient outcome to the ArtificialNeural Network and other tested scoring systems.