Case reports: a variety of clinical presentations and long-term evolution of Bochdalek hernias

Bochdalek hernias are the most common congenital diaphragmatic hernias, followed by Morgagni hernias. The failure of closure of the pleuroperitoneal membrane results in a posterolateral foramen, which can remain silent until adulthood. They remain a rare pathology with nearly a hundred cases published. Its clinical presentation is variable, making its diagnosis challenging for clinicians. Additionally, its symptoms are not necessarily representative of the content of the hernia. Its management is balanced between the abdominal and the thoracic approaches. However, no guidelines or algorithms are available to help surgeons in the decision-making process. We report here four consecutive cases of symptomatic Bochdalek hernias. Each case has a singular presentation, and we share how they were approached at our institution. In particular, this series shows no reoccurrence in 10+ years of follow-up in two cases and 20+ in one case, underlying the importance of surgical management when Bochdalek hernias are symptomatic.

Outcomes of patients older than 55 years undergoing abdominoplasty after bariatric surgery

BACKGROUND

Bariatric surgery has become widely performed for treating patients with morbid obesity, and the age limits are being pushed further and further as the procedure proves safe. After massive weight loss, many of those patients seek body-contouring surgery for excess skin and fat.

OBJECTIVES

To analyze the feasibility and the safety of abdominoplasty in patients older than 55 years old after bariatric surgery.

SETTING

University hospital medical center.

METHODS

We performed a retrospective review of prospectively collected data from patients aged older than 55 years who had undergone abdominoplasty following massive weight loss due to a bariatric surgery at a single institution from 2004 to 2017. The data analyzed included age, gender, preoperative body mass index, associated interventions, co-morbidities, and postoperative complications.

RESULTS

We retrieved records for 104 patients; 85.6% percent of them were female, and the mean age was 60.1 ± 3.9 years old. Of the 104 patients, 21 (20.2%) underwent a sleeve gastrectomy and 77 (74%) underwent a Roux-en-Y gastric bypass. The mean interval between the bariatric surgery and the abdominoplasty was 33.6 ± 26.9 months. The mean preoperative weight and body mass index were 76.1 ± 14.5 kg and 28.9 ± 4.5 kg/m², respectively. A total complication rate of 20% was observed. The only factor significantly associated with postoperative morbidity was the associated procedure (P = .03), when we performed another procedure at the same time as the abdominoplasty. Complications included postoperative bleeding in 5 patients (4.8%), seromas in 5 patients (4.8%), surgical site infections in 12 patients (11.5%), and wound dehiscence or ischemia in 2 patients (1.9%). No mortality occurred.

CONCLUSION

Abdominoplasty can be safely performed in carefully selected patients older than 55 years old after weight loss surgery, and does not present increased morbidity or mortality. We recommend that surgeons avoid adding concomitant procedures when possible, to decrease the risk of complications. It is also important to look at the patient's previous maximum BMI levels, as a higher maximum BMI can predict higher postoperative risks and longer hospital stays.

Feasibility and Efficiency of Sutureless End Enterostomy by Means of a 3D-Printed Device in a Porcine Model

Objective. The aim of this study is to present a 3-dimensional (3D)-printed device to simply perform abdominal enterostomy and colostomy. Summary Background Data. Enterostomy and colostomy are frequently performed during abdominal surgery. 3D-printed devices may permit the creation of enterostomy easily. Methods. The device was designed by means of a CAD (computer-aided design) software, Rhinoceros 6 by MC Neel, and manufactured using 3D printers, Factory 2.0 by Omni 3D and Raise 3D N2 Dual Plus by Raise 3D. Colostomy was scheduled on a human cadaver and on 6 Pietrain pigs to test the device and the surgical technique. Results. The test on the cadaver showed that the application of the device was easy. Test on porcine models confirmed that the application of the device was also easy on the living model. The average duration of the surgical procedure was 32 minutes (25-40 minutes). For the female pigs, return to full oral diet and recovery of a normal bowel function was observed at postoperative day 2. The device fell by itself on average on the third day. Until day 10, when euthanasia was practiced, the stoma mucosa had a good coloration indicating a perfect viability of tissues. No complications were observed. Conclusions. This is the first study that describes the use of a 3D-printed device in abdominal surgery. End-type colostomy using a 3D-printed device can be safely and easily performed in an experimental porcine model, without postoperative complications. Further studies are needed to evaluate its utility in the clinical setting.

Complications after laparoscopic sleeve gastrectomy: can we approach a 0% rate using the largest staple height with reinforcement all along the staple line? Short-term results and technical considerations

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is gaining acceptance among bariatric surgeons as a viable option for treating morbidly obese patients. We describe the results of a single center's experience with SG, revealing a low complication rate.

OBJECTIVES

The aim of the study was to analyze the short-term results of laparoscopic SG using exclusively black staples with staple-line reinforcement.

SETTINGS

University hospital, tertiary referral center for bariatric surgery.

METHODS

SG was performed in 434 consecutive patients from December 2014 to March 2017. A technique is described where all operations were performed with attention to avoiding strictures at the incisura angularis and not stapling near the esophagus at the angle of His. All the interventions were performed using black cartridges and staple-line reinforcement using bioabsorbable Seamguard. A prospective chart review was conducted to determine the occurrence of early complications.

RESULTS

Follow-up data were collected for all patients at 90 days postoperatively. A total complication rate of 4.4% was observed. No leaks occurred in any of the patients. One case of bleeding occurred that necessitated a surgical exploration, which found the origin of the bleeding to be a diaphragmatic vessel. The 90-day mortality rate was 0%.

CONCLUSION

SG can be performed with a low complication rate. Selection of the appropriate staple height and reinforcement of the staple line could play a major role in optimizing the results of SG.

Leak of the Bypassed Stomach after Laparoscopic Gastric Bypass, Presenting as Abdominal Wall Cellulitis

The development of surgical staplers devised for laparoscopy has enabled advancements in complex laparoscopic procedures, such as gastric bypass. This procedure, considered by many as the gold standard for bariatric surgery, is now frequently performed laparoscopically, with the advantages inherent in the minimally invasive approach. Technical failure of surgical staplers is, however, a well known complication of these devices in digestive surgery. We report the case of a leak of the bypassed stomach into the abdominal wall through a trocar site following laparoscopic gastric bypass. The mechanisms responsible for this life-threatening complication and the options to avoid it are discussed.

[A solitary tumor of the common bile duct: case report of a metastatic melanoma]

Primary malignant melanoma of the bile duct is very rare. We report a case of a malignant melanoma involving the common bile duct in a 41-year-old man. The patient presented to the hospital with an isolated jaundice and underwent pancreaticoduodenectomy. Absolute exclusion of a metastatic tumor is not entirely possible.

Laparoscopic fenestration for a symptomatic simple cyst of the spleen

Benign nonparasitic cysts of the spleen are a rare entity. Surgical treatment is indicated when they become symptomatic. Splenic conservative techniques are preferred, given the important immunologic role of the spleen. Laparoscopy has been used in the treatment of different splenic diseases with favorable results in terms of reduced postoperative discomfort, duration of hospital stay, and better cosmetic results. We report the case of a 35-year-old woman with a symptomatic simple cyst of the spleen that underwent a laparoscopic fenestration. The diagnostic and therapeutic implications are discussed focusing on the role of laparoscopy.

Gastric Necrosis: a Rare Complication of Gastric Banding

In the last decade, laparoscopic gastric banding has become an increasingly popular surgical option for morbidly obese patients, because of the minimally invasive and easy surgical technique, its reversibility, and the possibility to calibrate the stoma. Gastric necrosis, as a complication of laparoscopic gastric banding, has been only rarely reported. Herein described is the case of a 45-year-old obese patient with gastric necrosis occurring 2 years after the placement of the band. After initial conservative management, the patient underwent urgent surgery. A huge anterior gastric prolapse through the band was found to be responsible for necrosis of the herniated stomach. An upper polar gastrectomy was performed. The mechanisms responsible for this life-threatening complication are discussed.

Agenesis of the Right Liver: A Difficult Laparoscopic Cholecystectomy

Congenital agenesis of the right liver (ARL) is a rare condition that is generally asymptomatic. Congenital anomalies of the liver are generally diagnosed with current cross-sectional imaging modalities such as ultrasound, computed tomography, and magnetic resonance imaging (MRI) before surgery. However, discovery of a congenital anomaly of the liver only at time of surgery remains a possibility. Herein reported is the case of a 68-year-old woman undergoing laparoscopic cholecystectomy for symptomatic gallbladder stones as diagnosed on preoperative ultrasounds. Upon laparoscopic exploration of the upper abdomen, the right liver was not found; the gallbladder was located in the right subdiaphragmatic region posterior to the medial segment of the liver. A posterolateral interposition of the hepatic flexure of the colon was also found. Cholecystectomy was completed under laparoscopy. A postoperative MRI confirmed right liver agenesis. We discuss the technical difficulties of performing a laparoscopic cholecystectomy in the case of ARL and the advantages of a laparoscopic approach.

Anatomy of the presacral venous plexus: implications for rectal surgery

The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.