Laparoscopic repair of a large interstitially incarcerated inguinal hernia.

A 68 year old female presented for elective repair of an abdominal wall hernia. Preoperative CT imaging revealed a right inguinal hernia defect with hernia contents coursing cephalad between the external and internal abdominal oblique muscles. This was consistent with an interstitial inguinal hernia, a rare entity outside of post- traumatic hernias. At operation the hernia contents were reduced laparoscopically. The hernia was then repaired by transitioning to the totally extraperitoneal (TEP) approach using a 15cm X 15cm piece of polyester mesh. The patient had an uneventful recovery. Interstitial hernias are rare, difficult to diagnose and potentially dangerous if left untreated. There is no consensus on the ideal repair of these unique hernias. This represents a minimally invasive repair of an unusual hernia, with a novel approach to diagnose and manage the hernia and its redundant sac

A New Type of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGBP) is currently the most common bariatric procedure. One of its late complications is the development of internal hernia, which can lead to acute intestinal obstruction or recurrent colicky abdominal pain. The aim of this paper is to present a new, unusual, and so far not reported type of internal hernia. A common computerized database is maintained for all patients undergoing bariatric surgery in our departments. The charts of patients with the diagnosis of internal hernia were reviewed. Three patients were identified who developed acute intestinal obstruction due to an internal hernia located between the jejunojejunostomy and the end of the biliopancreatic limb, directly between two jejunal limbs with no mesentery involved. Another seven patients with intermittent colicky abdominal pain, re-explored for the suspicion of internal hernia, were found to also have an open window of the same location apart from a hernia at one of the typical hernia sites. Since this gap is systematically closed during RYGBP, no other patient has been observed with this problem. Even very small defects can lead to the development of internal hernias after RYGBP. Patients with suggestive symptoms must be explored. Closure of the jejunojejunal defect with nonabsorbable sutures prevents the development of an internal hernia between the jejunal loops at the jejunojejunostom

Laparoscopic Surgery for Small Bowel Obstruction due to Paracecal Hernia

Internal hernia related to paracecal hernia is a rare disease and is difficult to confirm by preoperative diagnosis. We recently encountered a case of an 83-year-old woman who had lower abdominal pain in her right quadrant. Based on physical findings and CT findings she was diagnosed as having small bowel obstruction by internal hernia around the cecum. She underwent emergency operation with laparoscopic surgery and was diagnosed with a paracecal hernia and treated laparoscopically. After we dissected the ventral wall of the hernia sac and enlarged the hernia orifice, we reduced the trapped small intestine into the abdominal space. We determined that the herniated portion of the small intestine was not necrotic and therefore did not resect it. Although paracecal hernia is a rare internal hernia, physicians should be aware of it as a differential diagnosis for small bowel obstruction because of its rapid progression to strangulation and necrosis. We highlight the importance of recognizing CT findings of paracecal internal hernia. Laparoscopy was effective both for making a definitive diagnosis and treating paracecal hernia with relatively little invasion

CT diagnosis of small bowel obstruction caused by internal hernia from persistent attachment of a Meckel's diverticulum to the umbilicus by the obliterated omphalomesenteric duct

We report a case of small bowel obstruction (SBO) caused by internal hernia from persistent attachment of a Meckel's diverticulum (MD) to the umbilicus by the obliterated omphalomesenteric duct that was diagnosed by multidetector CT and confirmed during laparoscopic surgery. Although clinical, pathological and radiological features of MD and its complications are well known, the diagnosis of MD is difficult to establish preoperatively. CT findings that allow the diagnosis of this very unusual cause of SBO are presented here with laparoscopic surgery correlation

Appendiceal abscess in a giant left-sided inguinoscrotal hernia: a rare case of Amyand hernia

The hernia of Amyand is an inguinal hernia containing the appendix in the sac. It is a rare pathology often diagnosed only intra-operatively. We report a case even more rare of a giant left-sided inguinoscrotal Amyand hernia with appendiceal abscess without clinical findings of incarceration/strangulation, occlusion, perforation, or acute scrotum and with the presence in the sac of the caecum and other anatomical structures (last ileal loops, bladder and omentum). The 68-years-old man patient successfully underwent surgical treatment only through the hernia sac (meshless repair according to Postempski technique)

A United Kingdom survey of surgical technique and handling practice of inguinal canal structures during hernia surgery

Background: Recent trials have assessed the impact of elective nerve division on patient outcome after inguinal herniorrhaphy. The aim of this study was to establish UK surgical practice of handling of structures in the inguinal canal during herniorrhaphy. Methods: A cross-sectional survey of all Fellows (n = 1113) of the Association of Surgeons of Great Britain and Ireland (ASGBI) was performed. The main outcomes were to determine method of inguinal hernia repair and routine practice for intra-operative handling of structures in the inguinal canal. Results: A total of 852 (77%) questionnaires were returned, of which 784 (92%) surgeons performed inguinal herniorrhaphy. Approximately two-thirds (63%) of responding surgeons performed less than 50 procedures per annum and 37% conducted more than 50 procedures annually. Mesh was the preferred method used by 90% of surgeons; 6% used non-mesh, and 4% used other (laparoscopic) methods. Routine practice in relation to the inguinal structures varied by volume of hernia surgery; surgeons who conducted more than 50 procedures annually were more likely to visualize and preserve inguinal nerve structures. However, inconsistency in the answers suggested confusion over anatomy. Conclusion: This is the first UK survey to investigate method of hernia repair and usual handling practice of inguinal canal structures. There was wide acceptance of the use of mesh in inguinal hernia repair, with the majority of UK surgeons favoring an open approach. Surgeons performing high volumes of herniorrhaphy were more likely to preserve, rather than transect, inguinal nerve structures. This variation in practice may confound assessment of long-term neuralgia and other post-herniorrhaphy pain syndromes

Imaging groin hernias

Clinical differentiation of direct inguinal hernias, indirect inguinal hernias, femoral and Spigelian hernias can be difficult particularly with small hernias and in obese patients. Diagnostic imaging can detect and characterize hernias more reliably, allow better surgical planning and possibly even prevent unnecessary surgery. Detection of complications occurring in groin hernias is also of importance. Hernial incarceration is particularly evident on ultrasound (US) performed during rest and abdomimal straining (Valsalva maneuver) in both the supine and erect postures. Hernial strangulation is visible both with US and with computed tomography (CT) with fluid appearing around the hernial sac contents.peer-reviewe

Early and late complications of bariatric operation.

Weight loss surgery is one of the fastest growing segments of the surgical discipline. As with all medical procedures, postoperative complications will occur. Acute care surgeons need to be familiar with the common problems and their management. Although general surgical principles generally apply, diagnoses specific to the various bariatric operations must be considered. There are anatomic considerations which alter management priorities and options for these patients in many instances. These problems present both early or late in the postoperative course. Bariatric operations, in many instances, result in permanent alteration of a patient\u27s anatomy, which can lead to complications at any time during the course of a patient\u27s life. Acute care surgeons diagnosing surgical emergencies in postbariatric operation patients must be familiar with the type of surgery performed, as well as the common postbariatric surgical emergencies. In addition, surgeons must not overlook the common causes of an acute surgical abdomen-acute appendicitis, acute diverticulitis, acute pancreatitis, and gallstone disease-for these are still among the most common etiologies of abdominal pathology in these patients

Understanding sports hernia (athletic pubalgia) - The anatomic and pathophysiologic basis for abdominal and groin pain in athletes

Recent publicity and some scientific reports suggest increasing success in treating an entity called “sports hernia” - more accurately named athletic pubalgia. The primary purpose of this article is to portray what we believe to be the key concept for understanding this wide variety of abdominal and groin injuries that afflict high performance athletes. These injuries have been plaguing athletes for a long time, and past treatments, based on concepts of occult hernia or simple strains, have generally failed. The former concepts do not take into account the likely mechanisms of injury or various patterns of pain that these athletes exhibit. The authors believe that the concept of a pubic joint or pubic dynamic complex is fundamental to understanding the anatomy and pertinent pathophysiology in these patients. Many injuries can now be treated successfully. Some of the injuries require surgery and others do not. In most cases, decisions regarding treatment and timing for return to full play require proper identification of the problems and consideration of a wide variety of medical, social, and business factors