Although uncommon, surgeons need to be aware of the epidemiology and treatment options for adult intussusception. The symptoms and signs are often non-specific and the surgeon might be faced with the diagnosis only at laparotomy. Computed tomography is the most useful imaging modality. An identifiable organic lesion is present in most cases, of which more than 50% are malignant (especially in the large bowel). Operative treatment is thus prudent. En bloc resection is recommended for ileo-colonic and colo-colonic intussusception. There is, however, a role of initial reduction in selected patients with ileo-ileal intussusception.

The preoperative diagnosis of Mirizzi syndrome is a challenge. Only constant vigilance during intraoperative dissection of the Calot's triangle will reduce the incidence of bile duct injury in Mirizzi syndrome that can occur in both open and laparoscopic surgery.

Patients below 40 years with breast cancer have tumours with a poorer prognostic profile. However, this did not translate into a poorer overall survival, and this might be attributable to more aggressive adjuvant treatment of younger patients.

The experience of a 0.43% bile duct injury rate is comparable to the best results from most large series in the West. Inflammation at Calot's triangle is an important associated factor for injury. Early recognition and prompt repair affords good results, and hepaticojejunostomy is recommended as the repair of choice.

Laparoscopic drainage of liver abscesses, in combination with systemic antibiotics, is a safe and viable alternative in all patients who require surgical drainage following failed medical or percutaneous treatment, and in those with large abscesses.

Laparoscopic varicocelectomy is safe and effective, causing minimal discomfort and allowing patients an early return to activity.

Objective  To assess the advantages of patient‐controlled analgesia (PCA) in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for urinary stones. Patients and methods  Between December 1995 and May 1996, a prospective study was carried out on 100 patients who underwent ESWL for urinary stones. The patients were assigned to two equal groups, one receiving PCA and the other pethidine (control). Patients in the PCA group self‐administered varying doses of intravenous alfentanil according to their pain tolerance, while those in the control group were given a single bolus dose of 1 mg/kg body weight intravenous pethidine by the attending urologist before the start of the procedure. The stone site, maximum energy level achieved, number of shock waves given, duration of procedure, pain scores, patient tolerance and acceptance were recorded to assess the efficacy of PCA compared with analgesia controlled by the physician. Results  Both groups were matched for age, body weight, stone location and number of shocks given. The PCA group received a mean of 1.03 mg alfentanil while the control group received a mean of 62.5 mg pethidine. The maximum discharge voltage of 16 kV was achieved in all but one patient (98%) in the PCA group whereas only 21 patients (42%) in the control group attained this level. The mean treatment duration was less in the PCA group (32.8 min) than in the control group (44.5 min), the mean pain score lower (3.76 and 4.62, respectively) and the incidence of nausea and vomiting much less (22% and 60%, respectively). In addition, all 21 patients in the PCA group who had received intravenous pethidine during previous sessions of ESWL chose PCA as the better form of analgesia. There were no adverse effects in the PCA group except for one patient whose arterial oxygen saturation decreased transiently. Conclusion  PCA enables the urologist to achieve better patient compliance through better pain control; its application has maximized the use of lithotripsy and the patients’ acceptability for this form of analgesia is confirmed. We recommend that this form of analgesia be used for ESWL.

IndicationsSpontaneous rupture of the bladder is a rare occurrence and therefore unlikely to be diagnosed pre-operatively. The majority of ruptures are due to blunt trauma or iatrogenic causes [ 1,2]. Pre-operative diagnosis can be made in such cases and suitable patients selected for laparoscopic repair, bringing the advantages of minimal access surgery to these patients.We report two cases of intraperitoneal rupture of the bladder, one spontaneous and the other of traumatic,' non-iatrogenic cause; both were repaired laparoscopically. The first patient was a 22-year-old lady who was admitted in August 1992, with a 1 week history of painful micturition culminating in severe abdominal pain. She had generalized peritonitis and catheterization revealed blood-stained urine. Emergency diagnostic laparoscopy performed after resuscitation revealed 1.5 L of bloody ascitic fluid and a 2 cm rupture at the dome of the bladder. Biopsy revealed acute innammation with perforation.The second patient was a 54-year-old man who presented with abdominal pain and an inability to pass urine following a car accident. There was no evidence of pelvic fracture or any other intra-abdominal injury. An urgent cystogram revealed an intra-peritoneal bladder rupture. Emergency diagnostic laparoscopy revealed a 3 cm rupture at the dome of the bladder with bloodstained urine in the peritoneal cavity. MethodUnder general anaesthesia, three working ports were placed a 5 mm port was sited above the suprapubic area and two other ports of 5 mm and 10 mm, at the same level as the sub-umbilical port on either side along the mid-clavicular line. The rupture was repaired laparoscopically with two layers of absorbable suture. The bladder was distended with 300 mL of saline to test for leaks. The peritoneal cavity was then lavaged thoroughly with saline before withdrawal of the ports and closure of the incisional wounds. 50Catheter drainage was continued for 1 week after the operation to allow adequate healing. No complications were encountered and there was little need for postoperative pain relief. Both patients recovered quickly with the second one returning to work after 2 weeks. The first patient had total bladder failure and was taught intermittent self-catheterization. Comparison with other methodsIn accodance with our practice, we performed a diagnostic laparoscopy to confirm the diagnosis and exclude other pathology or injury. Using established laparoscopic suturing techniques, we repaired the rupture as for open methods. Similar laparoscopic repairs have been reported for iatrogenic perforation of the bladder [2] and perforated peptic ulcers [3]. If laparoscopic surgery is not available, the only other surgical option would be conventional laparotomy followed by open repair of the bladder perforation. Advantages and disadvantagesWe feel that intraperitoneal rupture of the bladder from any cause can be safely repaired laparoscopically avoiding the problems associated with a large abdominal incision. The benefits of minimal access surgery to the pa...