[A focal abdominal swelling after an accident with a 'space scooter']

A 7-year-old boy presents at the Emergency Department with an abdominal swelling after an accident with a space scooter. He was diagnosed with a traumatic anterior abdominal wall hernia, for which he underwent surgical correction.

Laparoscopic Mesh Repair for Perineal Hernia after En Bloc Resection of an Aggressive Angiomyxoma Using a Modified Sacral Colpopexy Technique

STUDY OBJECTIVE

To demonstrate laparoscopic mesh repair of perineal hernia (PH) by a modified sacral colpopexy technique.

DESIGN

Step-by-step demonstration of the technique used for the surgical repair of PH after gynecologic surgery.

SETTING

PH is defined as a pelvic floor defect through which the intra-abdominal viscera may protrude [1]. The reported incidence of PH ranges from 0.6% to 3%, and it generally occurs after rectal or prostate surgery [2]. Owing to its low incidence, there is no standard procedure to treat PH [3]. Herein, we demonstrate a successful case of PH treatment with a composite mesh (Dual Mesh; W. L. Gore & Associates, Newark, DE) after gynecologic surgery by a modified laparoscopic sacral colpopexy technique, which was approved by our institutional review board.

INTERVENTIONS

The patient had undergone extralevator abdominoperineal excision for an aggressive angiomyxoma and developed a sigmoid colon-protrudent PH after the surgery [4]. The patient suffered from defecatory dysfunction and dysmenorrhea. A total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and mesh repair of the PH were performed at 2 years after the primary surgery, and they were successful without any intra- or postoperative complications. Because the pelvic floor defect was too large to secure the mesh by a simple placement, we applied the modified sacral colpopexy technique using 2-0 proline (ETHICON, Tokyo, Japan) to cover and support this defect. At 12 months after the second surgery, there was no sign of recurrence of PH and aggressive angiomyxoma, and the preoperative symptoms had diminished.

CONCLUSION

Laparoscopic mesh repair by the modified sacral colpopexy technique is safe and effective to manage PH.

Practice Patterns and Attitudes of Surgeons on the Use of Prophylactic Mesh to Prevent Parastola Hernia: A Cross-sectional Survey

Information about surgeons' attitudes toward using prophylactic mesh (PM) for parastomal hernia (PSH) prevention is limited.

PURPOSE

A survey was conducted to assess attitudes/beliefs and surgical practice related to PM use for preventing PSH.

METHODS

A cross-sectional email survey was conducted during April 2017 among members (surgeons) of the American Hernia Society, European Hernia Society, and International Hernia Collaboration. Survey items included participant demographic characteristics, knowledge about the incidence of PSH, number of permanent stomas created annually, beliefs/opinions (knowledge/interest) regarding the use of PM, and surgical practices (mesh type and position). Data were collected and tallied using SurveyMonkey. Descriptive statistics were used to analyze the data.

RESULTS

Of the 5445 emails sent, 497 responses were received, 235 (47.3%) from the United States and 197 (39.6%) from Europe. The majority of participants were general surgeons (371, 74.6%); a small percentage were colorectal surgeons (37, 7.4%). Most respondents (353, 71.0%) reported at least 11 years of surgical experience, with 37.3% reporting >20 years' experience. The majority of respondents (340, 68.4%) created <15 ostomies per year, more than half (252, 50.7%) consider the incidence of PSH 30% or below, and 107 (22%) use PM. The most common reason for not using mesh was concern about mesh-related complications (141, 41.5%). When asked about type of mesh, most surgeons (153/245, 62.4%) preferred permanent mesh and an open retromuscular approach (97/278, 34.9%).

CONCLUSION

Results of the present survey show ongoing ambiguity regarding the use of PM for PSH prevention. Education to increase awareness about the incidence of PSH and well-designed safety and effectiveness studies of preventive strategies are needed to help surgeons optimize PSH prevention strategies.

[An unexpected cause of nausea]

An 88-year old woman had a sudden onset of nausea and vomiting. She had an end colostomy following a curative resection of rectal cancer six years earlier. As we suspected a high gastrointestinal obstruction, an abdominal CT scan was made. This showed a paracolostomic herniation, including herniation of the stomach.

Traumatic abdominal wall hernia - a case of handlebar hernia

Traumatic abdominal wall hernia (TAWH) after blunt injury is uncommon. Diagnosis requires careful examination and high index of suspicion. We report a case of a 12-year-old boy who complained of painful abdominal swelling over the left iliac fossa after a bicycle-handlebar hit his abdomen. TAWH was diagnosed clinically and confirmed with ultrasound and computed tomography (CT) scan. He developed incarceration after 12 hours of admission and subsequently underwent primary repair without mesh. As TAWH is usually associated with other concomitant injuries, it is important that we are meticulous to rule out other serious concomitant injuries.

Littre's hernia: a systematic review of the literature

PURPOSE

A hernia containing Meckel's diverticulum is called a Littre's Hernia. It's a rare entity and its diagnosis is often incidental during routine hernia repair surgery. The objective of this study is the evaluation of the current evidence on Littre's hernias regarding their clinical presentation and optimal treatment approach.

METHODS

PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: August 1st, 2018) for studies reporting on Littre's hernias in adult population.

RESULTS

Forty-five studies met our inclusion criteria and reported collectively on 53 patients (21 males and 32 females) presenting at health care units with a Littre's hernia. The most common sites of occurrence were femoral (39.6%) and inguinal (34%). The vast majority of cases (77.4%) concerned incarcerated hernias. All patients underwent surgical hernia repair accompanied by a diverticulectomy and 16.9% of them received mesh. Only 7.5% of patients experienced immediate postoperative complications.

CONCLUSIONS

A Littre hernia is a rare complication of Meckel's diverticulum. It requires surgical attention and all medical professionals should be encouraged to report such cases to expand our experience and optimize the therapeutic approach.

Case report of traumatic abdominal wall hernia caused by seat belt

RATIONALE

Traumatic abdominal wall hernia (TAWH) is a rare form of hernia that is caused by disruption of the abdominal wall musculature and fascia. The diagnostic criteria and classification of TAWH are still unclear; furthermore, the ideal timing and method of surgical treatment are still unclear. Herein, we report a case of TAWH and describe the surgical approach used.

PATIENT CONCERNS

A 71-year-old Han Chinese female presented for swelling in the right lower abdominal quadrant. The patient underwent exploratory laparotomy because of a car collision before 1 year ago.

DIAGNOSIS

She was finally diagnosed with TAWH according to the abdominal computed tomography (CT) and surgery.

INTERVENTIONS

She was performed with an open surgery to repair the TAWH.

OUTCOMES

The patient was discharged without complications and showed no recurrence or complications during a follow-up period of 6 months.

LESSONS

TAWH is a rare form of hernia that presents a diagnostic and therapeutic challenge. The appropriate timing and approach of surgical treatment for TAWH depend on a case-by-case basis. This case highlights that delayed selective surgery may be more suitable for stable patients.

Use of Bioabsorbable Tissue Reinforcement Reduces Incidence of Internal Hernia in Roux-en-Y Gastric Bypass Patients

Internal hernias are one of the most devastating late, postsurgical complications associated with laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to determine whether placement of a bioabsorbable tissue matrix in soft tissue defects after gastric bypass resulted in a lower incidence of internal hernia development. Prospective database was used to identify all patients who underwent LRYGB between January 2002 and January 2016. These patients were then retrospectively reviewed to determine the development of internal hernia. Before 2009, the retro-Roux defect was left open during the primary operation and the defect at the jejunojejunostomy was closed with sutures or staples. Beginning in 2009, all soft tissue internal defects were reinforced with an 8 cm × 8-cm piece of bioabsorbable matrix. The incidence of subsequent internal hernia development was compared between these two groups: no bioabsorbable matrix versus use of a bioabsorbable matrix. A total of 2771 patients underwent LRYGB during our study period. From these, 1215 procedures were performed without tissue reinforcement and 1556 were performed using a bioabsorbable matrix. During the study period, 274 patients developed an internal hernia. Patients who did not have tissue reinforcement at closure had a significantly higher internal hernia rate [225/1215 (18.5%) vs 49/1556 (3.1%), P < 0.005]. This study demonstrates a statistically significant reduction in internal hernia formation after LRYGB with the addition of a bioabsorbable tissue matrix. Although prospective studies are needed, early evidence suggests that reinforcement with a bioabsorbable tissue scaffold is an effective method for minimizing internal hernias after LRYGB.

Internal Hernia in Pregnant Woman after Roux-en-Y Gastric Bypass Surgery

Laparoscopic Roux-en-Y gastric bypass has become the most common obesity surgery procedure worldwide over the last two decades. Many patients undergoing the procedure are women of reproductive age. This carries a risk for developing gastric bypass-related complications during pregnancy. One of the potentially serious risks is an internal hernia. We present a patient in the third trimester of pregnancy with an internal hernia following a laparoscopic Roux-en-Y gastric bypass for morbid obesity. We discuss the importance of computed tomography (CT) in the diagnosis of an internal hernia and review key CT findings including compression of the superior mesenteric vein, which proved to be crucial in diagnosing the internal hernia in this patient.

[Traumatic bicycle handlebar hernia in a child]

Traumatic abdominal wall hernia in children caused by a bicycle handlebar is a rare injury. This is a case report of a 15-year-old boy with a traumatic hernia in the right groin, where a physical examination revealed a small bulge in the right inguinal region, and an ultrasonography confirmed the diagnosis. The condition was initially treated conservatively. However, the patient had surgery performed three days later because of pain. Surgical repair with open layered closure is the preferred method. Laparoscopic sutured repair may also be performed, especially if diagnostic laparoscopy is performed anyway.

Randomized controlled trial of standard closure of a stoma site vs biological mesh reinforcement: study protocol of the ROCSS trial

BACKGROUND

Closure of complex and contaminated abdominal wounds is challenging and carries risks, including wound dehiscence and incisional hernia. Hernia formation at closed stoma sites occurs in up to 30% of patients. Use of biological meshes in these situations may provide a safe method of reducing these complications, especially long-term incisional hernias.

METHOD

The Reinforcement of Closure of Stoma Site (ROCSS) study is a Phase III multicentre randomized controlled trial (RCT) with an internal feasibility study. The primary objective of ROCSS is to assess whether a biological mesh (collagen tissue matrix) reduces the incidence of clinically detectable stoma closure site hernias at 2 years compared with standard closure techniques. Patients will be randomized in a 1:1 ratio to either standard suture (nonmesh) closure or closure with an intra-abdominal biological mesh reinforcement. Patients and outcome assessors are masked to treatment allocation. ROCSS aims to recruit 560 patients, with an option to recruit to 790 patients to increase power. The primary outcome measure is the occurrence of clinically detectable hernias years 2 years postrandomization. The secondary outcome measures are the radiological hernia rate at 1 year, incidence of symptomatic hernia, the surgical complication/re-intervention rate, quality of life, postoperative pain and cost-benefit analysis.

DISCUSSION

ROCSS is a multicentre RCT assessing the placement of a biological mesh at the site of stoma closure on clinical hernia rate. Our hypothesis is that reinforcing the stoma closure site with a collagen mesh is superior to the standard technique in reducing the risk of herniation at 2 years. These findings could influence future closure of stomas and other complex and/or contaminated abdominal wounds in settings around the world.

[A woman with acute abdominal pain after a gastric bypass]

A 35-year-old woman with a history of gastric bypass presented with acute abdominal pain, nausea and an urge to move. She showed normal vital signs. We found abdominal guarding and elevated ASAT, ALAT and LDH. A CT scan showed the whirl sign, caused by a mesenteric herniation through the Roux-en-Y gastric bypass.

Central mesh failure (CMF) after abdominal wall repair. A rare cause of recurrence

Central Mesh Failure (CMF) after abdominal wall repair (AWR) is uncommon but should be considered in case of recurrence. The mechanism is unclear and different theories are actually proposed, as the action of opposite forces acting in the abdominal wall on the prosthesis, and the characteristics of the device to be implanted. The use of lightweight meshes in some cases could be inadequate to withstand the bursting strenght of the abdominal wall. Three cases of incisional hernia recurrence due to central mesh failure are here reported. KEY WORDS: Abdominal wall repair (AWR), Central mesh failure (CMF), Hernia recurrence, Lightweight mesh.

An unusual complication of Meckel�s diverticulum: Littre�s hernia

Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract. Any hernia sacs containing Meckel’s diverticulum is called Littre’s hernia. It was described for the first time in 1700 by Alexis Littre. The diagnosis is unlikely to be made preoperatively and surgery is the treatment of choice. We report a rare case of Littre’s hernia who presented with clinical signs of intestinal obstruction.

Parastomal hernia: the need for consistency in prevention and management

Wendy Osborne, Educational Officer, ASCN UK, and Clinical Lead Ostomy Division, Coloplast Ltd, summarises the ASCN UK parastomal hernia workshop, which took place at the ASCN UK 2017 annual conference.

Internal hernia after proximal gastrectomy with jejunal interposition

Although internal hernia (IH) has been reported after laparoscopic distal or total gastrectomy with Roux-en-Y reconstruction, there are few reports of IH after proximal gastrectomy with jejunal interposition (PG-JI). The aim of this study was to analyze the incidence and clinical features of IH after PG-JI. This study retrospectively reviewed 71 patients who underwent PG-JI for gastric cancer at a single institution between July 2007 and December 2016. The median follow-up period after PG-JI was 50 months. Four patients (5.6%) developed IH. IH occurred in 3 of 38 patients after open PG (7.9%) and 1 of 33 after laparoscopic PG (3.1%; p = 0.38). The site of IH was Petersen in all cases, where the Petersen defect was not closed. All patients had abdominal pain at onset, and the CT revealed a whirl sign. Bowel resection was required in three patients (75%). There was no morbidity. IH after PG-JI occurred regardless of operative approach (open or laparoscopic). A high degree of suspicion for IH should be maintained in patients after gastrectomy with abdominal pain and a whirl sign on CT. Closure of the mesenteric defects should be considered to reduce the incidence of IH after surgery.

Laparoscopic Approach To A Rare Interstitial Incisional Hernia Following Appendectomy

Among the complications of an open appendectomy is the presentation of an incisional hernia. An interstitial or interparietal hernia is the one in which the hernia sac is present between the muscle layers of the abdominal wall which makes the presentation of a post-operative incisional interstitial hernia quite a rarity. A 52-year-old female was admitted through the outpatient clinic presenting with the complaints of discomfort and a bulge felt in the right hypochondrium for the last 3 years. Radiological investigations were able to delineate an interstitial incisional hernia through the previous open appendectomy scar. A laparoscopic approach to repair of this hernia was successfully undertaken without any complications. This is an interesting case of incisional hernia that may pose a diagnostic challenge to the unsuspecting surgeon with an unusual presentation which may cause unnecessary delays in treatment as well as unnecessary operations. Very few comparable cases can be found in literature.

[Clinical research progress of mesenteric internal hernia after Roux-en-Y reconstruction]

Postoperative internal hernia is a rare clinical complication which often occurs after digestive tract reconstruction. Roux-en-Y anastomosis is a common type of digestive tract reconstruction. Internal hernia after Roux-en-Y reconstruction, which occurs mainly in the mesenteric defect caused by incomplete closure of mesenteric gaps in the process of digestive tract reconstruction, is systematically called, in our research, as mesenteric internal hernia after Roux-en-Y reconstruction. Such internal hernia can be divided, according to the different structures of mesentric defect, into 3 types: the type of mesenteric defect at the jejunojejunostomy (J type), the type of Petersen's defect (P type), and the type of mesenteric defect in the transverse mesocolon (M type). Because of huge differences in the number of cases and follow-up time among existing research reports, the morbidity of internal hernia after LRYGB fluctuates wildly between 0.2% and 9.0%. Delayed diagnosis and treatment of mesenteric internal hernia after Roux- en-Y reconstruction may result in disastrous consequences such as intestinal necrosis. Clinical manifestations of internal hernia vary from person to person: some, in mild cases, may have no symptoms at all while others in severe cases may experience acute intestinal obstruction. Despite the difference, one common manifestation of internal hernia is abdominal pain. Surgical treatment should be recommended for those diagnosed as internal hernia. A safer and more feasible way to conduct the manual reduction of the incarcerated hernia is to start from the distal normal empty bowel and trace back to the hernia ring mouth, enabling a faster identification of hernia ring and its track. The prevention of mesenteric internal hernia after Roux-en-Y reconstruction is related to the initial surgical approach and the technique of mesenteric closure. Significant controversy remains on whether or not the mesenteric defect should be closed in laparoscopic Roux-en-Y anastomosis. This article is to review the reports and researches on internal hernia resulting from the mesenteric defect after Roux-en-Y digestive tract reconstruction in recent years, so as to promote understanding and attention on this disease. And more active preventive measures are strongly suggested to be taken in operations where digestive tract reconstruction is involved.

Delayed diagnosis of blunt carotid trauma in a seat belt syndrome with associated abdominal wall injury A case report

The aim of this case report is to be aware of occult carotid lesions in thoracic- abdominal trauma because, carotid artery injury consequent to blunt trauma is rare, affecting less than 1% of patients as reported in literature. A 45-years-old female, involved in a traffic accident, arrived to Emergency Room hemodynamically stable, with a Glasgow Coma Scale of 15, complaining abdominal pain, without any neurological signs. She underwent Computed Tomography (CT) scan that showed a complete disruption of left abdominal wall muscles, associated with massive bowel loops herniation. No free air nor other visceral injuries were found. The radiological brain evaluation was negative for neurological injuries. Considering the nature of the trauma, an explorative laparotomy was performed. During the fifth postoperative day, the patient presented neurological side signs with right facial-brachial-crural hemiparesis and expressive aphasia. Head and neck CT scan revealed a lesion of the left common carotid artery with distal embolization of the internal carotid. A left-carotid-axis revascularization procedure and a surgical endarterectomy were immediately performed. Patient was discharged after 20 days without neurological consequences. Physicians should be aware of neck vascular injuries when evaluating patients with multiple trauma, even in neurological asymptomatic patients without seatbelt abrasions of the neck skin.

KEY WORDS

Abdominal Hernia, Carotid artery, Seat belt, Surgery.