Asymptomatic Presentation of Bochdalek’s Hernia in an Adult

Bochdalek hernia, a type of congenital diaphragmatic hernia usually presents in the immediate neonatal period with respiratory distress. Presentation in an adult is rare and asymptomatic. We report one such case of Bochdalek hernia, in a 35 year old male, who presented only with mild chest discomfort on left side. Radiological investigations were suggestive of a huge left side Bochdalek hernia with stomach and intestines in the left thorax. This case emphasizes the rarity of presentation of Bochdalek hernia in adults and the importance of high clinical suspicion and the role of imaging and surgery in the accurate diagnosis of this abnormality.     

Primary Grynfeltt’s Hernia

Lumbar hernia is a rare defect of the abdominal wall. It accounts for 2 % of all wall hernias. It is divided in two levels: superior lumbar hernia, also known as Grynfeltt’s hernia (GH), and an inferior lumbar hernia or Petit’s hernia. GH is more commonly encountered in practice, and it is mainly posttraumatic in origin. Spontaneous primary GH is quite rare. Only 250 to 300 of such cases have been reported the in literature so far. The treatment of choice is retroperitoneal surgical approach and a meshplasty after complete reduction of its contents. Prognosis is usually excellent.     

Computed Tomographic Diagnosis of Incarcerated Meckel’s Diverticulum in a Patient with Bilateral Spigelian Hernia

Introduction  

Spigelian hernia is an uncommon abdominal wall hernia occurring through the linea semilunaris located near the lateral border of the rectus abdominis muscle.     

Ileo-Ileal Intussusception Due to Inverted Meckel’s Diverticulum

Meckel’s diverticulum is the most common congenital anomaly of the gastro-intestinal tract. It is generally asymptomatic. Occasionally, it may cause some complications such as bleeding, obstruction, diverticulitis and intussusception. We present a case of a 21-year-old female with intussusception due to inverted Meckel’s diverticulum. Diagnosis and therapy of inverted Meckel’s diverticulum is a subject of debate because of its rarity and the limited number of reports in the literature.     

Acute kidney injury: an intensivist’s perspective

The changing epidemiology of acute kidney injury (AKI) in adults and children has resulted in more patients being treated for kidney injury occurring in the context of multi-organ failure requiring treatment in the intensive care unit (ICU). AKI complicating critical illness has complex, multi-factorial etiology, and supportive care, including organ support, remains the mainstay of therapy. In the day-to-day management of AKI in the ICU two of the major challenges are the inadequacy of current diagnostics for the early identification of AKI and the relationship between hemodynamic resuscitation strategies and the development of AKI. This review focuses on these areas from the intensivist’s perspective. Given that the diagnosis of AKI is often delayed, the prevention of complications and limitation of secondary renal injury are of particular importance. Fluid overload is increasingly being associated with adverse patient outcomes in critical illness and may contribute to persistent renal dysfunction. Thus, hemodynamic management strategies in AKI should be tailored to limit fluid overload as much as possible.     

Tocilizumab Treatment for Nephrotic Syndrome Due to Amyloidosis in Behcet’s Disease

Renal involvement is an unusual but significant Behcet´s disease (BD) complication and AA amyloidosis appears to be the most common etiology. IL-6 is a pro-inflammatory cytokine with an important role in AA amyloidosis development. Tocilizumab (TCZ) is a humanized anti-IL-6 receptor antibody that has emerged as an effective and specific treatment in AA amyloidosis secondary to chronic inflammatory disorders. We report on a patient diagnosed with BD who developed nephrotic syndrome caused by renal AA amyloidosis with an excellent response to TCZ therapy.     

Incarcerated transdiaphragmatic intercostal hernia preceded by Chilaiditi’s syndrome

Transdiaphragmatic hernia most often develops after blunt or penetrating thoracoabdominal trauma. We report on the case of a 73-year-old man who underwent emergency ileocoecal resection for an incarcerated transdiaphragmatic intercostal hernia. The patients history included both a lumbotomy for right nephrectomy and Chilaiditis syndrome. The literature regarding both transdiaphragmatic intercostal herniation and Chilaiditis syndrome is reviewed in relation to the presented case.     

Chronic Groin Pain in Athletes: Sportsman’s Hernia with Bilateral Femoral Hernia

The differential diagnosis of chronic groin pain in athletes is a long list and its evaluation is a challenging task. Sports hernia, one of the common cause of these groin pains, had been managed both with open & endoscopic repairs in the past. We report a case of sports hernia in young footballer who presented with bilateral groin pain for 5 years. Endoscopic hernioplasty was done (by totally extra-peritoneal technique) which identified bilateral occult femoral hernia and were repaired simultaneously. Post op outcome was good with excellent results.     

Congenital Morgagni’s Hernia Presenting in Elderly Lady

Morgagni's hernia is an uncommon type of congenital diaphragmatic hernia. Large numbers are symptomatic but some may present in middle aged. Our patient was asymptomatic till 63 years of age. X-ray chest, for her recent onset exertional dyspne, was suspicious of right lung mass. CT thorax revealed right Morgagni’s type of diaphragmatic hernia, a very rare diagnosis at that age.     

De Garengeot’s Hernia: a Diagnostic Challenge

Surgical literature defines the case of acute appendicitis in a sac of femoral hernia as de Garengeot’s hernia. The diagnosis remains a very hard challenge for surgeon because the symptoms are aspecific and the most effective tools for preoperative evaluation (as abdominal computed tomography and abdominal ultrasound scan) can often be indeterminate or misinterpreted. We report the case of an 85-year-old white male admitted to our unit complaining of a 1-day history of vague abdominal pain, nausea, vomiting, and painful swelling in the right groin. Preoperatively, an incarcerated right femoral hernia was supposed and patient underwent surgery via oblique inguinal incision. The intraoperative finding was a de Garengeot’s hernia and an appendectomy with hernia repair was performed. Patient had a regular course and was discharged on the second postoperative day.     

Laparoscopic Appendectomy for Amyand’s Hernia: A Modern Approach to A Historic Diagnosis

Objectives  

This study seeks to discuss the management and diagnosis of Amyand’s hernia, an exceedingly rare diagnosis.     

Amyand’s Hernia in a 76-year-old Greek Male

The presence of an inflamed or non-inflamed appendix in an inguinal hernial sac is called Amyand’s hernia and it is a rare condition. The case is presented here of a 76-year-old Greek male with a known right reducible inguinal hernia, who presented at the hospital emergency department with the symptoms and signs of incarceration of the hernia. Intraoperatively, an inflamed appendix was revealed trapped in the hernial sac. To our knowledge this is the first case of Amyand’s hernia reported in a patient in Southwestern Greece.     

Strangulated Richter’s Umbilical Hernia - A Case Report

Richter’s hernia is an abdominal hernia in which part of the circumference of bowel entrapped in the hernial sac. The segment of the entrapped bowel is nearly always the distal ileum but any part of gastrointestinal tract from the stomach to the colon may become incarcerated. The most common sites for Richter’s hernia are the femoral ring (71%), deep inguinal ring (23%) and ventral or umbilical hernias (6%). The growing popularity of laparoscopic surgery has led to a new possible site for development of Richter’s hernia. In most cases as less than two thirds of the circumference of the bowel wall is involved, the lumen of the gut remains free and thus features of intestinal obstruction are often absent. Richter’s hernia is a deceptive entity whose high death rate can be reduced by accurate diagnosis and early surgery. We report a case of strangulated Richter’s umbilical hernia in a 36 years old male.     

Acute aortic dissection associated with Sheehan’s syndrome

A 69-year-old woman with Sheehan's syndrome who suffered acute Stanford type A aortic dissection had received corticosteroids and thyroid hormones for over 20 years. The entire ascending aorta was replaced in emergency graft replacement. We administered twice the usual dose of methylprednisolone during cardiopulmonary bypass and twice the patient's usual dose of prednisolone from postoperative day 1 to 6. The usual 100 micrograms of levothyroxine sodium was given orally from postoperative day 1. The patient's postoperative course was uneventful. This case emphasizes the importance of early active supplementary treatment with steroids and thyroid hormones for major surgery in patients with Sheehan's syndrome.     

Transition from Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair to Robotic Transabdominal Preperitoneal Inguinal Hernia Repair: A Retrospective Review of a Single Surgeon’s Experience

Background

There is a paucity of literature comparing laparoscopic to robotic inguinal hernia repair. We present a single surgeon’s transition from laparoscopic totally extraperitoneal (L-TEP) to robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair and compare outcomes from the two approaches.

Methods

This retrospective review and analysis of prospectively collected data compare outcomes during the transition from L-TEP to R-TAPP inguinal hernia repair by a single surgeon at one institution. Operating times and surgical outcomes and complications are analyzed. All consecutive L-TEP cases from November 2012 to August 2014 and all consecutive R-TAPP cases from March 2013 to October 2015 were included in the analysis.

Results

A total of 157 and 118 patients underwent L-TEP and R-TAPP inguinal hernia repair, respectively. The groups were similar regarding demographics and ASA class. A significantly higher number of complex cases were performed in the R-TAPP group compared to L-TEP group (n = 11 vs. n = 1, p = 0.0001). Mean surgical times were nearly identical (69.12 ± 35.13 min, R-TAPP; 69.05 ± 26.31, L-TEP) as were intraoperative and postoperative complication rates—despite the significantly higher number of complex cases in the R-TAPP group.

Conclusions

This is the largest study in the literature comparing a single surgeon’s experience transitioning from L-TEP to R-TAPP inguinal hernia repair. Results from the R-TAPP cases were similar to those achieved from laparoscopic cases. The robotic platform may have facilitated the execution of complex hernia cases during the proficiency phase.

     

Cross-Femoral Venous By-Pass (Palma’s Procedure) to Relieve Venous Hypertension Due to Retroperitoneal Leiomyosarcoma: A Case Report

Retroperitoneal leiomyosarcoma arising in, or involving, the inferior vena cava or the iliac vein are infrequent tumours. They are usually treated by “en-block” surgery. Venous reconstruction is usually not needed, since collateral circulation can adequately offset the main vessel flow. However, in rare cases, collateral circulation may be insufficient. The authors report a case of leiomyosarcoma infiltrating the left iliac vein. One week after radical resection surgery, the patient developed left leg compartmental syndrome due to venous hypertension.

The patient was successfully treated by thrombectomy of the left femoral vein and cross-femoral venous bypass (Palma’s Procedure) by means of an 8 mm diameter polytetrafluoroethylene (PTFE) prosthesis. To improve the flow inside the graft, an arterio-venous fistula (AVF) was performed. The choice of a prosthetic conduit, its diameter, and the AVF are discussed.     

Hyperhomocysteinemia Due to Levodopa Treatment as a Risk Factor for Osteoporosis in Patients with Parkinson’s Disease

Parkinson’s disease (PD) patients have been reported to have lower bone mineral density (BMD) and higher fracture risk than individuals without PD. We assessed the association between hyperhomocysteinemia due to levodopa intake and BMD in PD patients. We measured serum homocysteine (Hcy) concentrations and BMD in the proximal femur and lumbar spine of PD patients aged 55 years or older (n = 95) and three age-/gender-matched control subjects (n = 285). The prevalence of osteoporosis was higher in both men (2.5-fold) and women (1.7-fold) with PD than in controls, and adjusted odds ratios for osteoporosis were 3.57 (95% confidence interval [CI], 1.25–10.20) for men and 2.54 for women (95% CI, 1.31–4.93) with PD. Serum Hcy concentrations were significantly higher in PD patients (median = 13.0 μmol/l) than controls (median = 11.5 μmol/l) (P = 0.005). Serum Hcy concentrations were independently associated with BMD values at all proximal femur sites in all subjects (P = 0.005 to 0.012). In PD patients, higher serum Hcy concentrations were independently associated with higher fracture risk (P = 0.029). PD patients taking higher doses of levodopa had significantly higher serum Hcy concentrations (P = 0.013), and greater levodopa intake was associated with lower BMD values in some areas (P = 0.008 to 0.029). In conclusion, these findings indicate that hyperhomocysteinemia due to levodopa intake may be one additional risk factor for osteoporosis and fracture in PD patients. Reducing Hcy may be a therapeutic modality for treating osteoporosis in PD patients taking levodopa.