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Giant splenic artery aneurysms are extremely rare entities that have important clinical implications. The size and the natural history pose unique challenges in the management of these lesions. We present one such case that was associated with a primary arteriovenous malformation in the splenic hilum. This is the third largest aneurysm reported in literature so far and the characteristic feature is that this is the first case of a hilar arteriovenous fistula complicated by formation of a giant aneurysm and another smaller aneurysm. In our opinion the hilar malformation was congenital in origin and responsible for the formation of the two aneurysms. We also present an up to date review of literature on this subject.

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We report an unusual case of pituitary hyperplasia secondary to primary hypothyroidism clinically masquerading pituitary apoplexy. A 22-year-old female presented with intermittent headache, easy fatigability, facial puffiness, coarseness of facial features, and hoarseness of voice for six months duration. Diplopia and diminution of vision was also observed for the last 15 days. Brain imaging findings showed pituitary enlargement, the thyroid function test were suggestive of primary hypothyroidism. Patient did well with thyroid hormone replacement therapy.

Background. Laparoscopic right hepatectomy has become a standard procedure for laparoscopic resection in specialized centers;1-6 however, tumor involvement of the inferior vena cava (IVC) is still considered a contraindication. Here, we describe a safe technique of totally laparoscopic extended right hepatectomy to segment 1 combined with IVC resection using an anterior approach. Methods. We performed 61 totally laparoscopic right hepatectomies by an anterior approach between January 2009 and April 2014. The video illustrates this procedure in a 58-year-old female with bilateral colorectal liver metastases involving the right-anterior wall of the retrohepatic IVC. Right hepatectomy was performed by initial hilar dissection and ligation of vascular inflow followed by division of the hepatic parenchyma with en-bloc segmentectomy 1, to expose the left side of the retrohepatic IVC. The right hepatic vein was divided using an endoscopic vascular stapler. As the involved portion of IVC could be isolated with the application of a single vascular clamp, the right IVC wall was divided using an endoscopic stapler. Thereafter, posterior mobilization of the right liver was performed.Results. The surgical duration was 270 min and blood loss was 50 mL. The postoperative period was uneventful, and the patient was discharged 9 days after surgery.Histopathological examination confirmed the presence of a colorectal metastasis with tumor-free margin. Conclusion. We devised a secure procedure to perform totally laparoscopic right hepatectomy combined with IVC resection using an anterior approach; this may be a safe and useful technique to perform laparoscopic right hepatectomy.

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Introduction:The aim of the present study was to evaluate and compare the effect of clonidine 200 μg and gabapentin 900 mg and pregabalin 150 mg in attenuation of the hemodynamic response to laryngoscopy and intubation in normotensive patients undergoing elective surgery.Methods:Ninety adult patients between 18 and 60 years are enrolled in the study. Patients with American Society of Anesthesiologists Grade-I and Grade-II are included which are posted for elective surgery under general anesthesia. Patients were divided into three groups: A, B, and C and received oral drugs 90 min before induction of general anesthesia, pregabalin 150, gabapentin 900mg, and clonidine 200 μg, respectively. Hemodynamic parameters such as heart rate and blood pressure were noted just before the (basal) administration of the drug, and in operation room, readings were recorded before intubation (T0) and after intubation at 1, 3, 5, and 10 min. Sedation and anxiety score were noted after 1 h of oral administration of the drug.Results:Mean arterial pressure was well attenuated by pregabalin than others, and mean heart rate following laryngoscopy and intubation was attenuated by clonidine group significantly.Conclusion:We conclude that oral pregabalin and gabapentin attenuate blood pressure response fairly well and heart rate significantly attenuated by clonidine. All three drugs are very effective for relieving anxiety and improving sedation.

Background. The Pringle maneuver is widely used in liver surgery to reduce intraoperative blood loss.1 However, total vascular inflow occlusion is frequently associated with ischemia reperfusion injury leading to postoperative liver dysfunction and impaired recovery. 2-4We describe herein an original procedure of modified Pringle maneuver (MPM) during laparoscopic liver resection with selective clamping of hepatic arterial inflow. Methods. Of 183 laparoscopic major hepatectomies performed at the Institute Mutualiste Montsouris between January 1998 and March 2014, 19 patients required vascular clamping, and MPM was used in 6 patients. The video showed this procedure in a 58-year-old woman with multiple colorectal liver metastases planned for laparoscopic right trisectionectomy. After the division of the right hepatic artery and the right portal vein, the parenchymal transection was performed with 12 mm Hg of pneumoperitoneum pressure using MPM in order to control the bleeding. Results. The total operative time was 187 min and estimated blood loss was 70 ml. A right trisectionectomy were performed successfully with a purely laparoscopic procedure. After an uneventful postoperative recovery, the patient was discharged on the fifth postoperative day. Among 6 patients in whom this technique was applied, only one patient experienced grade II postoperative liver failure according to Clavien-Dindo classification. Conclusions. Selective clamping of hepatic arterial inflow may be a preferred surgical strategy for high-risk patients, with elective application of this maneuver preemptively in all cases where excessive bleeding is anticipated. Electronic supplementary material The online version of this article CONFLICT OF INTEREST