Symptomatic Bochdalek Hernia in an Adult

Background and Objectives:

Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Symptomatic Bochdalek hernias in adults are infrequent and may lead to gastrointestinal dysfunction or severe pulmonary disease. We describe our experience with this rare entity.

Methods:

A retrospective chart review was performed on a single patient for data collection purposes.

Results:

The patient is a morbidly obese 53-year-old female who presented with epigastric pain and diffuse abdominal tenderness. Computed tomography scans of the chest and abdomen revealed a small posterior diaphragmatic defect containing gastric fundal diverticulum. Laboratory work and imaging revealed no other findings. Laparoscopic repair of the Bochdalek hernia was done via an abdominal approach and utilized primary closure with an AlloDerm patch apposed to the defect. The patient has had significant clinical improvement and continues to do well at 9 months postoperatively.

Conclusion:

Laparoscopic repair of symptomatic adult Bochdalek hernias can be performed successfully and may result in significant clinical improvement.     

Management of giant inferior triangle lumbar hernia (Petit's triangle hernia): A rare complication following delayed breast reconstruction with extended latissimus dorsi myocutaneous flap

INTRODUCTION

Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors.

PRESENTATION OF CASE

The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18 cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted.

DISCUSSION

Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair.

CONCLUSION

The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications.     

Right sided transmesentric hernia: A rare cause of acute abdomen in adults

INTRODUCTION

Transmesenteric mesocolic hernias are a rare cause of acute abdomen in adults with few reported cases in published literature.

PRESENTATION OF CASE

We report a rare case of a 30-year-old male with right-sided transmesenteric hernia of ileum due to a congenital mesocolic defect resulting in acute abdomen, presenting as acute abdomen. The hernia was reduced, small bowel inspected for gangrene and mesenteric hernia repaired, following which the patient made a good recovery and was discharged 5 days later.

DISCUSSION

The insidious onset of transmesenteric herniae and lack of specific radiological or laboratory investigations reaffirms the importance of surgeons maintaining a high index of suspicion for this surgical emergency.

CONCLUSION

Transmesentric hernia though rare can present as a case of acute abdomen in an emergency. The diagnosis is purely by a CT scan and close monitoring of the patient''s general condition in cases of non-specific abdominal pain is essential to identify the rare deteriorating patient for early surgical intervention and optimal outcome.     

Epigastirc hernia presenting as a giant abdominal interparietal hernia

INTRODUCTION

Epigastric hernia is a rare form of ventral abdominal hernia. When neglected it can attain an impressive size causing it un-aesthetic effect in addition to diagnostic difficulties.

PRESENTATION OF CASE

Presented is a 60-year-old female farmer with a 10-year history of a voluminous mass in the anterior abdominal wall.

DISCUSSION

Surgery revealed an epigastric hernia presenting as an interparietal hernia. The hernia was an omentocele with a grossly distended hernia sac filled with about 2.5 l of serous fluid. No similar case has been found in the medical literature.

CONCLUSION

Epigastric hernia can attain voluminous dimensions and present as a non-inguinal interparietal hernia.     

A case of a bleeding benign gastrocolic fistula in 2014

INTRODUCTION

In the era of proton pump inhibitors in the treatment of peptic ulcer disease, the incidence of a gastrocolic fistula arising from unoperated gastric ulcers is extremely low.

PRESENTATION OF CASE

We present the case of a 68-year old farmer who presented with melaena and was found to have a benign gastrocolic fistula in the setting of untreated peptic ulcer disease, chronic NSAID ingestion and heavy alcohol intake. The diagnosis was made by gastroscopy. En bloc surgery was undertaken due to the size of the fistula and concomitant significant bleeding of the ulcer which would not have made it amenable to medical management.

DISCUSSION

The symptoms of a gastrocolic fistula are undifferentiated and the diagnosis can easily be missed in the setting of other complications such as bleeding or perforation of a hollow viscus. Barium enamas are the most accurate for the diagnosis but gastroscopy with biopsy is usually performed to rule out malignancy. The mainstay of treatment is usually surgical, though patients can be medically managed if he/she is not a surgical candidate.

CONCLUSION

Benign gastrocolic fistulas are rare and its diagnosis is easily missed.     

Duplication of vas deferens-A rare anomaly with review of literature

INTRODUCTION

Isolated duplication of vas deferens is a rare anomaly with only eleven cases reported in medical literature. Unawareness regarding this rare anomaly can lead to inadvertent injury to the vas during inguinal hernia surgery or failure of vasectomy procedure.

PRESENTATION OF CASE

A 27-year-old gentleman was diagnosed with isolated duplication of vas during left sided open inguinal hernia surgery. He had no other genito-urinary anomaly. Patient had an uneventful recovery from surgery.

CONCLUSION

It is a rare anomaly and unawareness regarding this condition can lead to catastrophic consequences during inguinal hernia and vasectomy surgeries.     

Laparoscopic Nissen Rossetti fundoplication in situs inversus totalis—A blessing in disguise

INTRODUCTION

Laparoscopic Nissen fundoplication and Nissen Rossetti fundoplication represent two different surgical approaches for treating hiatus hernia. We report a Laparoscopic Nissen Rossetti fundoplication (LNRF) for gastro esophageal reflux disease (GERD) in a patient with situs inversus totalis (SIT).

PRESENTATION OF CASE

: A 38-year-old man with SIT was diagnosed with sliding hiatus hernia. We performed Laparoscopic Nissen Rossetti procedure for this patient. The patient was discharged on first postoperative day after he tolerated oral liquids.

DISCUSSION

SIT is a rare anomaly presenting in 1–2 per 10,000 individuals. As this rare anomaly (SIT) led preoperative anticipation of respiratory and blood loss complications the above procedure was chosen. Less operating time, less calculated blood loss and improvement of symptoms with no associated gas bloating syndrome was noted especially with SIT.

CONCLUSION

We recommend relook into the Laparoscopic Nissen Rossetti fundoplication as an effective procedure in GERD especially with rare anomalies like SIT.     

Giant inguinal hernia: Report of a case and reviews of surgical techniques

INTRODUCTION

Inguinal hernia is one of the most surgical common diseases. Giant inguinal hernia is more unusual and significantly challenging in terms of surgical management. It is defined as an inguinal hernia that extends below the midpoint of inner thigh when the patient is in standing position.

PRESENTATION OF CASE

A 67-year-old male presented with giant right-side inguinal hernia with symptoms of partial colonic obstruction and significant weight loss. Barium enema revealed ascending colon, cecum and ileum contained in hernia sac without significant lesions of large bowel. He underwent hernia repair with omentectomy. Hernioplasty with polypropylene mesh was performed without any complications. He recovered uneventfully.

DISCUSSION

There were several repair techniques suggested by published articles such as resection of the content and increased intraabdominal volume procedure. Many key factors for management of the giant inquinal hernia were discussed. A new classification of the giant inquinal hernia was described.

CONCLUSION

Surgical repair for the giant inquinal hernia is challenging and correlated with significant morbidity and mortality due to increased intra-abdominal pressure.     

A large incarcerated Meckel's diverticulum in an inguinal hernia

INTRODUCTION

Littre''s hernia is a rare finding consisting of a Meckel''s diverticulum inside of a hernia sac. Clinically, it is indistinguishable from a hernia involving small bowel and therefore may be difficult to diagnose pre-operatively.

PRESENTATION OF CASE

We report a case of an inguinal hernia involving an unusually large Meckel''s diverticulum measuring 15 cm in length. The diverticulum was resected using a linear GI stapler and the hernia was repaired without complication.

DISCUSSION

Meckel''s diverticulum is an embryologic remnant of the vitelline duct occurring in 1–3% of the adult population with an estimated 4% becoming complicated and presenting with intestinal obstruction, infection, bleeding or herniation. Surgical resection is the recommended treatment for any Meckel''s diverticulum causing symptoms. In the case of a Littre''s hernia, resection of the diverticulum should be followed by repair of the fascial defect in a standard fashion.

CONCLUSION

Littre''s hernia, although rare, should be a consideration at the time of repair for any abdominal hernia involving small bowel as resection of the Meckel''s diverticulum is critical in avoiding recurrent complications.     

Current Trends in Laparoscopic Ventral Hernia Repair

Background and Objectives:

The purpose of this study was to analyze the surgical technique, postoperative complications, and possible recurrence after laparoscopic ventral hernia repair (LVHR) in comparison with open ventral hernia repair (OVHR), based on the international literature.

Database:

A Medline search of the current English literature was performed using the terms laparoscopic ventral hernia repair and incisional hernia repair.

Conclusions:

LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. Incidental enterotomy can be avoided by using a meticulous technique and sharp dissection to avoid thermal injury.     

A rare etiology of acute abdominal syndrome in adults: Gastric volvulus – Cases series

INTRODUCTION

Gastric volvulus is a rare surgical emergency with a high mortality rate that requires urgent surgical management.

PRESENTATION OF CASE

A 19-year-old male and 51-year-old female patient underwent emergency surgery with a prediagnosis of acute abdomen syndrome, and a 60-year-old female patient underwent elective surgery due to diaphragmatic hernia. Abdominal exploration revealed gastric volvulus together with perforation in received emergency surgery patients, and a mesenteroaxial gastric volvulus due to diaphragmatic defect in third patient.

DISCUSSION

Gastric volvulus is classified into four subgroups depending on the mechanism of development, and organoaxial form is the most common type of gastric volvulus. The most challenging step in diagnosing gastric volvulus is the consideration of this diagnosis.

CONCLUSION

Preoperative diagnosis is often difficult, and its management involves surgical correction of the pathology followed by institution of resuscitative treatment.     

Morgagni hernia treated by reduced port surgery

INTRODUCTION

The laparoscopic repair of a rare diaphragmatic Morgagni hernia using the reduced port approach is described.

PRESENTATION OF CASE

An 85-year-old female presented with a 2 days history of upper abdominal discomfort and loss of appetite. We diagnosed her condition as a Morgagni hernia by morphological studies and performed laparoscopic mesh placement with a multi-channel port and 12-mm port. This elderly patient had a rapid postoperative recovery. A 2-year follow-up CT showed no recurrence of the hernia.

DISCUSSION

Recent trends in laparoscopic procedures have been toward minimizing the number of incisions to reduce invasiveness. This case indicated that the reduced port approach can be considered a suitable and safe procedure for treatment of Morgagni hernia.

CONCLUSION

The reduced port approach is a good indication for Morgagni hernia.     

Ileosigmoid knotting—A disastrous double closed loop obstruction

INTRODUCTION

Ileosigmoid knotting (ISK) is a rare entity which needs prompt recognition and immediate surgical intervention to avoid catastrophic complications caused by gangrenous bowel and subsequent peritonitis. Preoperative investigations are only diagnostic of obstruction and CT findings are helpful but are not always available.

PRESENTATION OF CASE

This case report describes a 22 year old male presenting with acute abdomen managed with emergency exploration in view of findings of peritonitis. Intra-operatively an ileal segment was wrapped around the base of sigmoid colon with gangrenous ileal segment suggesting ISK. Resection of gangrenous ileal segment with double barrel ileostomy was done. Patient tolerated procedure well.

DISCUSSION

Patients with ileosigmoid knotting present with frank obstruction and require immediate medical and surgical treatment. This condition rapidly progresses to gangrenous bowel, generalized peritonitis and sepsis with very high mortality.

CONCLUSION

Early diagnosis, prompt fluid resuscitation, preoperative antibiotics and immediate surgical exploration are keys for optimal management of this condition.     

Direct inguinal hernia containing bladder carcinoma: A case report and review of the literature

INTRODUCTION

Inguinal hernia containing bladder carcinoma is a very rare occurrence.

PRESENTATION OF CASE

We report a case of a male patient who presented with a left groin hernia containing an irregular mass. The hernia was repaired without the use of mesh and a partial cystectomy was done.

DISCUSSION

Only 1–3% of all inguinal hernias involve the bladder, with very few reports containing a carcinoma.

CONCLUSION

Treatment consists of removing the tumor and repairing the hernia.     

Morbidity and mortality of pancreatic tumors undergoing surgical treatment

Background

Pancreatic cancer has a high mortality rate due to late diagnosis and aggressive behavior. The prognosis is poor, with 5-year survival occurring in less than 5% of cases.

Aim

To analyze demographic characteristics, comorbidities, type of procedure and early postoperative complications of patients with pancreatic cancer submitted to surgical treatment.

Methods

Cross-sectional study with analysis of 28 medical records of patients with malignant tumors of the pancreas in a 62 month. Data collection was performed from the medical records of the hospital.

Results

Of the total, 53,6% were male and the mean age was 60.25 years. According to the procedure, 53,6% was submitted to duodenopancreactectomy the remainder to biliodigestive derivation or distal pancreatectomy. The ductal adenocarcinoma occurred in 82,1% and 92,9% of tumors were located in the pancreatic head. Early postoperative complications occurred in 64,3% of cases and the most prevalent was intra-abdominal abscess (32,1%). Among duodenopancreactectomies 77,8% had early postoperative complications.

Conclusion

Its necessary to encourage early detection of tumors of the pancreas to raise the number operations with curative intent. Refinements in surgical techniques and surgical teams can diminish postoperative complications and, so, operative morbimortality can also decrease over time.     

Management of cervical thoracic duct cyst with cyst-venous anastomosis

INTRODUCTION

Cervical thoracic duct cyst (CTDC) is a rare cause of lateral neck mass. Surgical excision with ligation of the cervical thoracic duct is the current standard for definitive management with symptomatic patients. We report the first case of an alternative method of management performing a cyst venous anastomosis for decompression.

PRESENTATION OF CASE

A 77 year old female presented with a six month history of left arm pain, swelling and a left-sided cystic neck mass. She was treated with cyst-venous anastomosis between the cyst wall and the left internal jugular vein. At two year follow-up, she has had resolution of pain and no recurrence of the mass.

DISCUSSION

Many potential etiologies have been proposed for CTDC, though surgical management of this rare problem has consistently required cyst excision and thoracic duct ligation. Few innovative modes of therapy have been developed to address this problem in a less invasive manor. Maintaining a more natural thoracic duct anatomy decreases the likely of complications associated with duct ligation.

CONCLUSION

Cyst-venous anastomosis for the management of CTDC provides an effective, novel form of treatment which maintains the integrity of the thoracic duct and avoids potential complications associated with duct ligation.     

Swelling of the right thigh for over 30 years—The rare finding of a De Garengeot hernia

INTRODUCTION

Femoral hernias may – in some rare cases – contain the appendix, a phenomenon called de Garengeot hernia. It is usually an incidental finding in hernia repair. We found our case to be of interest because of the long standing femoral swelling before peracute appendicitis led to its removal.

PRESENTATION OF CASE

We present the case of a 71-year-old woman with a swelling of the right medial thigh for over more than 30 years. When the swelling suddenly grew in size and became tender, she was referred to our emergency department. Sonographically as well as clinically a femoral hernia was diagnosed. Intraoperatively, the appendix was found and open appendectomy as well as a hernioplasty was performed.

DISCUSSION

Open appendectomy is an elegant and safe procedure to repair a long standing de Garengeot hernia. Most case reports call for extensive diagnostics such as CT scan etc. We found a sonography of the femoral region to be conclusive.

CONCLUSION

Apart from the inherent risk of sudden incarceration in hernias, De Garengeot hernias can also develop peracute appendicitis years after their formation. This differential diagnosis needs to be taken into consideration in patients presenting with the clinical signs of a femoral hernia.