Laparoscopic Inguinal Hernia Repair: Technical Details, Pitfalls and Current Results

Expanding view of minimal invasive surgery horizon reveals new practice areas for surgeons and patients. Laparoscopic inguinal hernia repair is an example in progress wondered by many patients and surgeons. Advantages in laparoscopic repair motivate surgeons to discover this popular field. In addition, patients search the most convenient surgical method for themselves today. Laparoscopic approaches to inguinal hernia surgery have become popular as a result of the development of experience about different laparoscopic interventions, and these techniques are increasingly used these days. As other laparoscopic surgical methods, experience is the most important point in order to obtain good results. This chapter aims to show technical details, pitfalls and the literature results about two methods that are commonly used in laparoscopic inguinal hernia repair

Laparoscopic Rare Abdominal Hernia Treatment

Diaphragm and abdominal wall hernias are rare, and they may be congenital or acquired. Spiegel hernia incidence is between 0.1 and 2%. Morgagni hernia is comprising only 2–3% of all diaphragmatic hernias. Most Spiegel and Morgagni hernias are diagnosed late because of their non-specific symptoms and asymptomatic clinical presentation. The major symptoms are abdominal pain, vomiting, and dyspnea. Computed tomography (CT) shows the hernia sac content, strangulation or incarceration in the content, and detailed anatomical information about surrounding tissue. Surgery is the main treatment option except patients who have severe comorbidity. Spiegel hernia surgery can be performed open or laparoscopic. Intraperitoneal onlay mesh (IPOM), total extraperitoneal procedure (TEP), transabdominal preperitoneal (TAPP) procedure, or partial transabdominal laparoscopic methods are minimal invasive surgery options. In the repair of Morgagni hernia, surgical options may be laparoscopy, laparotomy, thoracotomy, or thoracoscopy

Laparoscopic treatment of morgagni hernia: Two case reports

Morgagni hernias account for only 2–3% of all diaphragmatic hernias, and most of them (91%) are rightsided. Most Morgagni hernias are diagnosed in childhood, but rarely diagnosis may be late because they can be asymptomatic or present nonspecific-nonrespiratory symptoms. Thus, Morgagni hernia diagnosis is incidental in the majority of adulthood cases. The defect arises from a fusion failure of the diaphragm with the central arches. Surgery is the main treatment modality of the Morgagni hernia due to defect enlargement and strangulation- incarceration risks. In this paper, we present two Morgagni hernia cases treated with laparoscopic surgery. Minimal invasive techniques can be used in Morgagni hernia with all advantages

Topical Steroids to Treat Granulomatous Mastitis: A Case Report

Idiopathic granulomatous mastitis (IGM) is a rare and chronic benign disease of the breast. Histologically, the disease presents as an intense inflammatory reaction with non-caseated granulomas that are the characteristic symptom of the disease. No consensus exists on the best treatment modality for this disease. In this report, we present a patient with granulomatous mastitis who was treated successfully with low-dose oral and topical steroids. Our aim here is to discuss various approaches for IGM in view of the literature and present treatment with topical steroids, which has not been reported

Analiza rezultata dijagnostičke ekscizijske biopsije limfnih čvorova: 12-godišnje iskustvo jednog centra

Lymph node biopsy is indicated in patients with suspected malignancy or lymphadenopathy due to unclarified reasons. Lymph node biopsy can be performed as fine needle aspiration biopsy, core biopsy, or excisional lymph node biopsy. In particular, the diagnosis of malignant lymphoma is considered insufficient for oncological treatment unless classified into subgroups. Core biopsy and excisional biopsy can be performed to diagnose lymphoma and classify it into subgroups. Core biopsy may also be limited in some cases for the diagnosis of lymphoma. Therefore, patients are referred to surgical departments for excisional lymph node biopsy. It was aimed herein to analyze the results of excisional lymph node biopsies performed for diagnostic purposes in our department. Data on 73 patients having undergone diagnostic excisional lymph node biopsy at Sakarya University Medical Faculty Training and Research Hospital between January 2008 and January 2020 were retrospectively analyzed. Patients were evaluated in terms of age, gender, biopsy site, pathological diagnosis, number and diameter of lymph nodes excised. Patients younger than 18 years of age, those with sentinel lymph node biopsies, and lymph node dissections performed for any known malignancy were excluded from the study. Statistical data analysis was done using SPSS statistical software. There were 37 (50.7%) female and 36 (49.3%) male patients, mean age 52.07 (18-90) years. Axillary lymph node biopsy was performed in 32 patients, inguinal lymph node biopsy in 29 patients, cervical lymph node biopsy in 3 patients, intra-abdominal lymph node biopsy in 6 patients, mediastinal lymph node biopsy in 1 patient, and supraclavicular lymph node biopsy in 2 patients. All of the lymph node biopsies were performed as excisional biopsy. Malignancy was detected in 36 (49.3%) patients. In 37 (50.3%) patients, the causes of lymphadenopathy were found to be benign pathologies. When the causes of malignant disease were examined, it was observed that 23 (31.5%) patients were diagnosed with lymphoma. Hodgkin lymphoma was detected in 5 patients diagnosed with lymphoma, and non-Hodgkin lymphoma was found in 18 patients. Metastatic lymphadenopathy was observed in 13 (17.8%) patients. Reactive lymphoid hyperplasia (26%) and lymphadenitis (20.5%) were found among the causes of benign lymphadenopathy. The number of excised lymph nodes was between 1 and 4, and their diameter was between 9 and 75 mm (mean: 29.53±15.56 mm). There was no statistically significant difference between benign and malignant patients according to gender, age, lymph node diameter, number of lymph nodes excised, and excisional lymph node biopsy site. For diagnostic lymph node biopsy, fine-needle aspiration biopsy and core biopsy should be performed primarily. If lymphoma is suspected in the diagnosis, fine-needle aspiration biopsy is not necessary. In this case, it is believed that it is more appropriate to perform core biopsy first. If the core biopsy is insufficient for diagnosis, it is more appropriate to perform surgical biopsy in order to cause no delay in diagnosis and treatment. Excisional biopsy is a method that can be safely performed and does not cause severe morbidity in palpable peripheral lymphadenopathies. Although it does not cause severe morbidity because it is an invasive procedure, excisional biopsy should be performed in a selected patient group.Biopsija limfnih čvorova indicirana je u bolesnika sa sumnjom na zloćudnu bolest ili s limfadenopatijom nejasnog uzroka. Biopsija limfnih čvorova može se izvesti kao tankoiglena aspiracijska biopsija, širokoiglena biopsija ili ekscizijska biopsija limfnih čvorova. Dijagnoza zloćudnog limfoma smatra se naročito nedostatnom za onkološko liječenje ako nije provedena klasifikacija u podskupine. Širokoiglena biopsija i ekscizijska biopsija mogu se provesti kako bi se dijagnosticirao limfom i klasificirao u podskupine. Širokoiglena biopsija može se također u nekim slučajevima pokazati ograničenom u dijagnosticiranju limfoma. Zato se bolesnici upućuju u kirurške odjele na ekscizijsku biopsiju limfnih čvorova. Cilj ovoga istraživanja bio je analizirati rezultate ekscizijskih biopsija limfnih čvorova izvedenih u dijagnostičke svrhe na našem odjelu. Retrospektivno su analizirani podaci za 73 bolesnika podvrgnutih dijagnostičkoj ekscizijskoj biopsiji limfnih čvorova u Sveučilišnoj bolnici Sakarya između siječnja 2008. i siječnja 2020. godine. Analizirani su sljedeći podaci: dob, spol, mjesto gdje je izvedena biopsija, patološka dijagnoza, broj i promjer ekscidiranih limfnih čvorova. Iz istraživanja su bili isključeni bolesnici mlađi od 18 godina, oni s biopsijom sentinel limfnih čvorova te oni s disekcijom limfnih čvorova zbog bilo kakve poznate zloćudne bolesti. Statistička analiza podataka provedena je pomoću statističkog programa SPSS. Bilo je 37 (50,7%) ženskih i 36 (49,3%) muških bolesnika srednje dobi od 52,07 (18-90) godina. Biopsija aksilarnih limfnih čvorova izvedena je u 32, ingvinalnih limfnih čvorova u 29, cervikalnih limfnih čvorova u 3, intra-abdominalnih limfnih čvorova u 6 bolesnika, mediastinalnih limfnih čvorova u 1 bolesnika i supraklavikularnih limfnih čvorova u 2 bolesnika. Sve biopsije limfnih čvorova izvedene su kao ekscizijske biopsije. Malignitet je otkriven u 36 (49,3%) bolesnika, dok su u 37 (50,3%) bolesnika uzroci limfadenopatije bile dobroćudne patologije. Ispitivanje uzroka zloćudne bolesti pokazalo je da je limfom bio dijagnosticiran u 23 (31,5%) bolesnika. Hodgkinov limfom otkriven je u 5 bolesnika u kojih je dijagnosticiran limfom, dok je ne-Hodgkinov limfom utvrđen u 18 bolesnika. Metastatska limfadenopatija zabilježena je u 13 (17,8%) bolesnika. Među uzrocima dobroćudne limfadenopatije nađeni su reaktivna limfoidna hiperplazija (26%) i limfadenitis (20,5%). Broj izvađenih limfnih čvorova bio je od 1 do 4, a njihov promjer bio je od 9 do 75 (srednja vrijednost 29,53±15,56) mm. Nije bilo statistički značajne razlike između bolesnika s dobroćudnom i zloćudnom limfadenopatijom u dobi, spolu, promjeru limfnih čvorova, broju izvađenih limfnih čvorova i mjesta izvođenja ekscizijske biopsije limfnih čvorova. Za dijagnostičku biopsiju limfnih čvorova treba najprije napraviti tankoiglenu aspiracijsku biopsiju i širokoiglenu biopsiju. Ako se dijagnostički posumnja na limfom tada tankoiglena aspiracijska biopsija nije potrebna. U tom slučaju smatra se da je primjerenije najprije napraviti širokoiglenu biopsiju. Ako se širokoiglena biopsija pokaže nedostanom za postavljanje dijagnoze tada je primjerenije napraviti kiruršku biopsiju kako ne bi došlo do kašnjenja u dijagnozi i liječenju. Ekscizijska biopsija je metoda koja se može sigurno izvoditi i ne uzrokuje teži pobol kod palpabilnih perifernih limfadenopatija. Iako ne uzrokuje teži pobol s obzirom na to da je invazivni postupak, ekscizijsku biopsiju treba izvoditi u odabranoj skupini bolesnika

Primary Small Cell Carcinoma of the Lung Presenting with Breast and Skin Metastases

Cutaneous metastases originating from an internal cancer are relatively uncommon in clinical practice, and metastatic lesions to the breast are rarer than those to the skin. Skin metastases of lung cancer, which may be the first sign of the disease, usually indicate progressive disease and a poor prognosis. We describe a 47-year-old male who presented with recurring masses in the lumbar region bilaterally and the right breast. Immunohistochemical findings and radiological imaging suggested lung cancer. This is the first reported case of small cell lung cancer metastasizing to two separate, uncommon sites, the skin and breast

A Case of Achalasia Presented with Cardiopulmonary Arrest

Achalasia is a rare disorder characterised by obstruction of the distal oesophagus and subsequent dilation of the proximal oesophagus. Patients generally complain of gastrointestinal symptoms; however, pulmonary symptoms and complications may also occur. A 35-year-old woman was brought to our emergency service complaining of sudden-onset dyspnea that started 15 minutes earlier during dinner. She suffered a cardiopulmonary arrest due to aspiration 5 minutes after being admitted to the emergency room and was intubated. Thoracic computed tomography examination showed that her oesophagus was filled with undigested food. Heller cardiomyotomy and Dor fundoplication was performed via laparotomy with the diagnosis of primary achalasia, and she was discharged as uneventful on the 5th postoperative day

CT Findings of Patients with Small Bowel Obstruction due to Bezoar: A Descriptive Study

Purpose. The aim of this study was to present the computed tomography (CT) findings of bezoars that cause obstruction in the small bowel and to emphasize that some CT findings can be considered specific to some bezoar types. Materials and Methods. The records of 39 patients who underwent preoperative abdominal CT and subsequent operation with a diagnosis of intestinal obstruction due to bezoars were retrospectively analyzed. Results. In total, 56 bezoars were surgically removed from 39 patients. Bezoars were most commonly located in the jejunum (n=26/56, 46.4%). Sixteen (41.0%) patients had multiple bezoar locations in the gastrointestinal tract. Common CT findings in all patients were a mottled gas pattern and a focal ovoid or round intraluminal mass with regular margins and a heterogeneous internal structure. Furthermore, some CT findings were determined to be specific to bezoars caused by persimmons. Conclusions. Preoperative CT is valuable in patients admitted with signs of intestinal obstruction in geographic regions with a high bezoar prevalence. We believe that the correct diagnosis of bezoars and the identification of their number and location provide a great advantage for all physicians and surgeons. In addition, some types of bezoars have unique CT findings, and we believe that these findings may help to establish a diagnosis

Colorectal neoplastic emergencies in immunocompromised patients: preliminary result from the Web-based International Register of Emergency Surgery and Trauma (WIRES-T trial)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception