Knowledge of pathophysiological basis of laparoscopic procedures, that is, the influence of CO2 pneumoperitoneum (PNP) on the body in particular, can prevent the complications during laparoscopy to occur. Standard intra-abdominal pressure (IAP), which is used during laparoscopic surgery, is 12-15 mm / Hg. The direct effect of CO2 pneumoperitoneum is a result of mechanical action of the gas and increasement of intra-abdominal pressure (IAP). The indirect effect of CO2 pneumoperitoneum is caused by the absorption of gas inserted into the abdomen. Analysis of published articles that assess the effects of CO2 pneumoperitoneum on the body and abdominal organs contributes to a better usage of the laparoscopic method. Different techniques in laparoscopy, created as an alternative to standard CO2-pneumoperitoneum, have the task to reduce the risks for patients with comorbidity and simultaneously raise the abdominal wall and allow the surgeon to perform smooth operation, which is especially important for ASA III and ASA IV patients. Alternative techniques can be divided into three groups: laparoscopy using pneumoperitoneum with low intra-abdominal pressure (up to 8 mm / Hg), laparoscopy using retractors abdominal wall and limited pneumoperitoneum, and laparoscopy without the use of gas (gasless laparoscopy; raising the abdominal wall retractor only ). Low insufflation pressure in the abdomen (up to 8 mm / Hg) is beneficial for patients with laparoscopic procedures and its routine usage in elderly patients and patients with severe cardiorespiratory diseases, should be common practice. Gasless laparoscopy was created because of the need to prevent the negative effects of increased intra-abdominal pressure on the body during laparoscopy, primarily in patients with high comorbidity (ASA III and ASA IV). When compared to other techniques, numerous studies prefer laparoscopy with low insufflation pressure, but in practice this is not done routinely, yet each technique is applied selectively, according to the needs and condition of the patient, which is the most appropriate. To avoid the side effects of CO2 pneumoperitoneum, which is important in high-risk patients, it is more likely to operate on low IAP (6-8 mm / Hg) or use gasless laparoscopy. This is especially important for long – duration operations. DOI: 10.7251/SMDEN1501066H (Scr Med 2015:46:66-72)

ABSTRACT The aim: of this study was to compare two methods of polypropylene mesh fixation for inguinal hernia repair according to Lichtenstein using fibrin glue and suture fixation. Material and Methods: The study included 60 patients with unilateral inguinal hernia, divided into two groups of 30 patients – Suture fixation and fibrin glue fixation. All patients were analyzed according to: age, gender, body mass index (BMI), indication for surgery–the type, localization and size of the hernia, preoperative level of pain and the type of surgery. Overall postoperative complications and the patient’s ability to return to regular activities were followed for 3 months. Results and discussion: Statistically significant difference in the duration of surgery, pain intensity and complications (p<0.05) were verified between method A, the group of patients whose inguinal hernia was repaired using polypropylene mesh–fibrin glue and method B, where inguinal hernia was repaired with polypropylene mesh using suture fixation. Given the clinical research, this systematic review of existing results on the comparative effectiveness, will help in making important medical decisions about options for surgical treatment of inguinal hernia. Conclusions: The results of this study may impact decision making process for recommendations of methods of treatment by professional associations, making appropriate decisions on hospital procurement of materials, as well as coverage of health funds and insurance.

Background: Knowledge of the pathophysiological basis of laparoscopic procedures, in particular the impact of CO2pneumoperitoneum (PNP) on the body, can prevent onset of complications during laparoscopy. Design and Methods: Standard intra-abdominal pressure (IAP), which is used during laparoscopic surgery, is 12 to 15 mm Hg. The direct effect of CO2-pneumoperitoneum is a consequence of the mechanical action of the gas, and increased intra-abdominal pressure. The indirect effect of CO2-pneumoperitoneum caused by the absorption of gas from the abdomen. Analysis of articles that evaluated the effects of CO2-pneumoperitoneum on the body and intra-abdominal organs contributes to an even better use of the laparoscopic method. Results: The results of numerous experimental and clinical studies have confirmed that increased IAP and CO2-pneumoperi toneum intraoperatively causing reduction the portal venous blood flow, increasing venous stasis, reduced glomerular filtration, reduced Tiffeneau-index and pulmonary compliance what it can lead to hemodynamic and cardiac disorders. Consecutive intraoperative acidosis and hipercarbia impact the function of intra-abdominal organs and heart. Conclusion: To avoid the side effects of CO2-pneumoperitoneum, which is important in patients with ASA II and more often as necessary to be operate with low pressure (IAP: 6-8 mm Hg) or use gasless laparoscopy.

Staplers are widely used in gastrointestinal surgery. We used a circular stapler to establish gastroduodenal anastomosis after distal gastrectomy in a recent case. After separating the stomach from the duodenum, we anastomosed the posterior wall of the stomach to the duodenum by introducing the circular stapler through the part of the stomach that was to be resected. Then we separated the distal part of the stomach with a linear stapler, and so completed the distal gastric resection. The advantages of this technique are that it is simple and safe.

Primary rectal adenocarcinoma metastatic to the breast is an exceedingly rare event. Its management differs from that of primary breast cancer, as illustrated by this case. A 63-year-old woman presented with a breast lump 30 months after abdominoperineal resection for rectal adenocarcinoma, stage T₃N₁M₀ (stage III), followed by standard postoperative radiochemotherapy. The patient underwent a mammography and ultrasonography. A CT scan of the abdomen showed metastatic disease. An excisional biopsy of the breast lump was performed; morphological features were identical to the original rectal cancer. Immunohistochemical results were negative for estrogen and progesterone receptors and gross cystic disease fluid protein-15, and intensity positive for cytokeratin 20 and carcinoembryonic antigen. The patient died after treatment with palliative chemotherapy. Metastatic disease from rectal carcinoma to the breast is a marker for disseminated metastatic spread with poor prognosis.

Surgery of the gallbladder has evolved tremendously over the last century. Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. In recent times, innovative techniques of natural orifice transluminal endoscopic surgery (NOTES) and transumbilical single-port (TUSP) or single-incision laparoscopic surgery (SILS), have been applied in gallbladder removal as a step towards even more less-invasive procedures. We report a 49-year-old woman with calculosis which were submitted to a single-port transumbilical laparoscopic cholecystectomy, first time done on the Surgical Clinic of Tuzla, and first time in Bosnia and Herzegovina.

BACKGROUND/AIM The aim of this study was to establish Gastrointestinal Life Quality Index scores of patients before and after laparoscopic and open cholecystectomy comparing scores after both operations. SETTINGS AND DESIGN The 120 patients were involved in this prospective study, 51 male and 69 female, 59 of patients were underwent by laparoscopic method and rest of them, 61, by open method on Surgery Clinic on Clinical university center in Tuzla in period from February 2006 to October 2006, chosen by consecutive method. This study evaluates patients life quality according to score of Gastrointestinal Life Quality Index. METHODS Patients have been tested two weeks before the operation and in two, five and ten weeks of post-operative period. Except from Gastrointestinal Life Quality Index total score, established scores,a parts of life quality are: symptoms, physical function, emotional and mental status and also social activities. STATISTICAL ANALYSIS USED For analysis of achieved results, SPSS (Statistical Package for Social Sciences, V 10.01) program with statistical parameters was used: average values and standard deviation. Out of statistical tests, we used Chi-square test and Student t-test. Values p < 0,05 have been accepted as statisticaly significant. RESULTS The results of the study confirm a working hypothesis that patients life quality after two and five weeks of postoperative period is significantly better (p < 0.05) in laparoscopic method group versus open method group. Also, in domains Gastrointestinal Life Quality Index symptoms, physical function, emotional and menthal status and social activities results are significantly better (p < 0.05) in the laparoscopic cholecystectomy group than in open method cholecystectomy group. Ten weeks of post-operative period, results showed that these two groups have no difference in life quality in total score, also in domain score. CONCLUSION This comparative study between laparoscopic and open cholecystectomy according to patients life quality aspects confirms advantages of laparoscopic technique in comparison to open cholecystectomy method.

BACKGROUND AND OBJECTIVES Although many advantages of laparoscopic method in regard to open one have been already proved, both surgical methods may cause a certain number of complications. The goal of the study is to answer the question: Is Laparoscopic Cholecystectomy (LC) safer and more satisfactory method than open cholecystectomy (OC) concerning number, type and seriousness of complications? DESIGN AND SETTING Prospective, the research includes all patients in Bihać Cantonal Hospital during 2007, who had cholecystectomy, laparoscopic or open, because of the gallbladder calculosus. METHODS The study has included 476 patients who had cholecystectomy and who satisfied standards for this study. Of the total number of patients, 293 of them had laparoscopic cholecystectomy and 183 open cholecystectomy. Total number of complications is established for each group of patients. RESULTS The study has shown that there were more complications in patients operated by open method than in those operated by laparoscopic cholecystectomy (p < 0.0001). Intraoperative bleeding was found in 1.63% of patients with open and 0.68% with laparoscopic cholecystectomy. Postoperative collection in abdomen were found in 2.18% of patients with open and 1.02% with laparoscopic method. The most common complications for open cholecystectomy were: infection (2.73%), hematoma in the wound (2.73%) and urine retention (2.18%). CONCLUSION It can be concluded that LC and OC are comparable procedures for the treatment of gall stone disease in terms of complications, results of this study demonstrate that LC is essentially a safe procedure with low complicatins, morbidity and mortality rate.

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.

Introduction: Laparoscopic cholecystectomy is a method of choice in the treatment of calculous gallbladder. There is a clear evidence of changes in hemostatic parameters during this surgical procedure, which can result in thromboembolic complications. The aim of the study was to evaluate changes in D-dimer values, as a marker of hypercoagulability in patients treated with laparoscopic cholecystectomy. Patients and methods: The study included total of 60 patients, divided into two groups, one treated with classic (open) and other with laparoscopic method. Blood samples were taken from all patients before, during the surgery and 24 hours and 5 days after the procedure with consequent determination of D-dimer levels. Results: Blood samples of patients in both groups manifested higher values of D-dimer during the operation, 24 hours and 5 days after the procedure. We have found elevated values of D-dimer 5 days after the surgery in the group of patients treated with laparoscopic cholecystectomy with 2.5 times higher levels compared to values measured preoperatively. Conclusion: Our results suggest that there is an increased fibrinolytic activity after laparoscopic cholecystectomy, which demands more detailed and complete study on tromboembolism prophylaxis.

Introduction: Laparoscopic cholecystectomy (LC) is a method of choice for chronic gallbladder calculus. Surgeon’s experience and sophistication of the work method itself have brought a number of advantages in comparison to open cholecystectomy (OC). Particularly, the advantage corresponds to decreased immune response of the organism on surgical stress. The aim of this study was to define the level of surgical stress through immune response of the organism on stress. Patients and Methods: One hundred patients were involved in the study, 50 of whom were treated by LC method and the other 50 by open method. The patients were of middle age group, between 47 and 57 years of age, mostly female. C-reactive protein was studied as one of the parameters of the organism’s immune response during LC and OC, and also a number of leucocytes, erythrocytes, haemoglobin and hematocrit after LC and OC procedures. C-reactive protein is a biochemical marker, as an organism’s response to stress and the aim of this study is to confirm the CRP values during surgical treatment of chronic calculus of the gallbladder through different surgical methods: conventional or open surgery and laparoscopic surgery which is considered less invasive. Number and frequency of intra-operative and post-operative complications during laparoscopic and open cholecystectomy were also compared. The erythrocytes, haemoglobin and hematocrit and leucocytes, were also determined in both groups of patients with the aim to confirm the hypothesis that the laparoscopic cholecystectomy is a less invasive method compared to the classic or open method. Results and Discussion: The results have confirmed the hypothesis that the laparoscopic cholecystectomy surgical method is less invasive and showed that the value of CRP is much less in post-operative period after LC than OC. In this way, decreased immunological response of the organism on the surgical laparoscopic procedure were confirmed in this study. Decreased value of leucocytes was determined in laparoscopic technique in the post-operative period in comparison to open technique. The number of erythrocytes, hematocrots and haemoglobin were not significantly different in the post-operative period during LC and OC. Complications such as bleeding, bile leakage, subphrenic abscess, post-operative pancreatitis, post-operative wound infection, hernias of post-operative sections and keloid were present more in OC than in LC. Conclusion: Inflammation of early protective homeostatic immune response on post-operative wound characterises the production of C-reactive protein as one of the activities of cellular and humoral mechanisms. This comparative study between laparoscopic and open cholecystectomy in light of immune response of the organism to stress, number and type of intra-operative and post-operative complications, confirmed advantages of laporascopic technique in comparison to open method.

Resectional surgery on rectum, finishing with continued colo-rectal anastomosis by the classical manual technique, were burdened by a great number of post surgery complications of dehiscentio over 60%. If we take into reconsideration a high number of mortality 5-20% then we have valid reasons for developing modern and safer methods of surgical intervention of these patients. Two groups of 60 patients each, have been analyzed. They have been operated at the Surgical clinic University Clinical Center Tuzla because of rectum malignancy. The first group of patients where the colo-rectal anastomosis was manually operated was done between 1995-1998. In the second group of the patients being operated, colorectal continuity was done by stapler. The patients were operated in time period 2001-2002. The medium evaluation time was 20 months, for each group. All the patients were operated in elective programme, after endoscopic treatment and ph diagnosis done. The patients from the both analyzed groups were operated by the same surgeons. Preoperational procedure and postoperational observation was fullfilled according to the unified protocol. The patients with their colo-rectal continuity having been by stapler had a shorter surgery time, and less transfusion of blood. They had less ureter lesion. Also they have got a shorter hospitalization time with less number of anastomotic complications. Dehiscenc as well as bleeding. The patients with colorectal anastomosis made manually had more repeated surgeries. The patients from the manual group of the surgeries had more anastomotic relapses. The difference in the number of post operational strictures in both analyzed groups was not noticed. The patients with stapler colorectal anastomosis had no mortality. The manual group had one lethal case. The important thing that is noticed is a larger number of stapler colorectal anastomosis, not because of the illnes incidence increase but decrease of abdominoperineal rectum amputation. The patients have been safely operated from the oncologic point of wiev. They have continuing anastomosis which was not burdened with a larger number of morbidity and mortality. This was possible to do by improving surgical strategy and technique and introduction of stapler in every day surgical practice.

BACKGROUND In a very short time, malignant obstructions of distal choledochus cause a lot of damage to the liver function that may result in serious intra operative and postoperative complications and consequent high hospital mortality. Contradictory results with respect to the recovery of the liver function and origin of intra operative and postoperative complications lead us believe in the necessity of the evaluation of the preoperative placement of billiar stent in these patients, knowing that these patients see the doctor in the advanced stage of the disease with the relatively high level of the liver function damage. The goal of this research was a quantitative and qualitative analysis of intra operative and postoperative complications as well as high hospital mortality in both groups of subjects so that through this kind and scope of complications and mortality rate we could indirectly reach the conclusion relating to efficiency of the billiar stent placement. Another goal of the research was the analysis of liver tests before the operation and ten days after the operation with both groups of subjects so that, based upon the speed of their normalization, the conclusion could be reached in relation to the speed and level of the liver function recovery after the performed pancreatoduodenectomy. RESULTS The subjects from the first group had more expressed symptoms of jaundice and high temperature and fever whereas in respect to the other presented symptoms there was no statistically significant difference. Preoperative values of ALT and AST values and the total values of bilirubin and C-reactive protein were statistically significantly higher in the first group of subjects (p<0.05). Contrary to that, ALP and GGT enzymes value were higher but there was no statistically significant difference between the compared groups. After the operation the normalization of all mentioned parameters of the liver function occurs in both groups of subjects but ALT, AST, ALP and GGT enzymes values and total bilirubin values in the first group of subjects were closer to the reference values. Based upon these data we can conclude that the liver function recovery also was better and faster. By analyzing intra operative complications no statistically significant difference was found between the compared groups. The total ratio of postoperative complications was 32 %, compared to 40 %, which is not a statistically significant difference. With respect to fistula and infections there were no statistically significant differences. Other postoperative complications in both groups were almost equally present and are not statistically significant. CONCLUSION Better liver function recovery in the first group of subjects and the equal ratio of complications in both group of subjects, justifies the application of preoperative placement of billiar stent under our conditions.

BACKGROUND The aim of this study were evaluated intraoperative and postoperative complication, and reasons for conversions among first 200 and last 200 procedures inside about 2 000 where we performed laparoscopic cholecystectomy in our clinic. MATERIAL AND METHODS Retrospective-prospective we analised overall complication rate, operative time and reasons for conversions in first and last 200 procedures where we performed laparoscopic cholecystectomy. We use the USA technique for operation with three troacars. Demografic dates about patients, intraoperative finding and hospital statistic was the same in both groups. RESULTS In the first group we have 8 (4%) intraoperative complications and 12 (4.8%) postoperative complications, the average operative time was 77.8 (+/- 12.01) minutes, and the number of conversions was 10 (5%). In first group we had two cases with intraopertive bleeding (1%), two cases with common bile duct injury (1%), three cases with adhesions (1.5%) and one cases of negative effects of resorption of CO2. In the second group we have 5 (2.5%) intraoperative complications, and 8 (4%) postoperative complications, the average operative time was 56.8 (+/- 12.03) minutes, and we done 5 (2.5%) conversions. The most important postoperative complications were: postoperative pancreatitis, deep veins thrombosis and postoperative abscess collection in both groups. We had statistically significant difference between first and last 200 procedures LC. Hospital stay were 3.10 (+/- 1.06) days for first, and 2.90 (+/- 67.09) days for second group. CONCLUSIONS Analyses of our results after first and last 200 patients showed lower rate of complications, conversions and reoperations in the second group. Our results we explain with better surgery technique, more experience of surgeons and better surgery equipment.