Ultraschallscreening auf abdominale Aortenaneurysmen (AAA)

Background

Abdominal aortic aneurysm (AAA) rupture is associated with a high mortality. The only preventive therapy is early diagnosis and elective surgery of rupture prone AAAs. Using B-mode sonography AAAs can be detected early with great reliability. Thus, a population-based ultrasound screening might lower the risk of abdominal aortic aneurysm ruptures.

Materials and methods

A literature analysis (until June 2014) was performed in the databases of MEDLINE, PubMed, and SCOPUS including all randomized controlled trials (RCT), systematic reviews, meta-analyses, health technology assessments (HTA reports) and medical guidelines on AAA screening. The following keywords were used: abdominal aortic aneurysm, ultrasound screening, evidence, guidelines. Clinically relevant endpoints were the following: AAA-associated mortality, overall mortality, number of elective AAA operations, number of ruptured AAAs and emergency surgery for different follow-up intervals.

Results

In four RCTs men between 65 and 83 years either had a single or no ultrasound examination of the abdominal aorta. Older women were only analyzed in one RCT. The meta-analysis of the RCT results shows that ultrasound screening caused a significant decrease of AAA-associated mortality, number of ruptured abdominal aneurysms, and number of emergency operations, whereas the number of elective surgeries significantly increased. Overall mortality was only moderately decreased by AAA screening.

Conclusion

Evidence was provided in population-based RCTs and meta-analyses for the efficiency of ultrasound based AAA screening for men older than 65 years. Presently the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWIG) are evaluating a national ultrasound-based AAA screening program for Germany. However, additional clinical trials are necessary to assess risk groups especially men under 65 years, women with nicotine abuse and cardiovascular diseases which were underrepresented in previous studies.     

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS: The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs. MATERIAL AND METHODS: 110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model. RESULTS: Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard). CONCLUSIONS: Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.     

Emergency Non-ruptured Abdominal Aortic Aneurysm

OBJECTIVES: To investigate symptoms and early mortality (<30 days) following open surgery for emergency, symptomatic non-ruptured abdominal aortic aneurysm (AAA). DESIGN: Retrospective cohort study. PATIENTS AND METHODS: During the period 1983-1994, 129 patients had an emergency admission, followed by surgery, for symptomatic non-ruptured AAA. Sixty-one received surgery within 24 h of admission and 68 received surgery more than 24 h after admission (median 135 h, inter-quartile range: 51-239 h). During the same period 239 patients had elective surgery for non-ruptured AAA. Early mortality (<30 days), symptoms and co-morbidities were recorded. Data were retrieved from the patient records. RESULTS: Mortality (30 days) was 18% in the 61 patients having surgery within 24 h of emergency admission for non-ruptured AAA. Mortality following either delayed surgery (semi-elective) after emergency admission or elective surgery was 4.2% (p=0.0002). Four out of 11 patients who died within 30 days following an acute operation had previously been declared unfit for elective surgery. One additional emergency patient had been found unfit for open surgery, but survived a delayed operation. CONCLUSION: The high mortality rate of patients with non-ruptured, symptomatic AAA undergoing surgery within 24 h of admission appears to be influenced by several factors, including co-morbidities and the acute operation. We propose that the 30-day mortality for non-ruptured AAA should be reported in two categories: mortality rate for elective surgery and mortality for surgery performed within 24 h of emergency admission. The term 'emergency non-ruptured' is a suitable term for the latter group.     

Medikamentöse Therapie zur Risikoreduktion und Progressionshemmung nicht interventionspflichtiger abdomineller Aortenaneurysmen

Background

An ultrasound screening examination is highly effective in the detection of abdominal aortic aneurysms (AAA) in males above the age of 65 years. Patients with small AAAs (diameter Objectives The effectiveness of medicinal treatment approaches on the overall cardiovascular risk and on the growth and rupture rate of small AAAs was analyzed.

Material and methods

This article presents and discusses the currently available literature on the effectiveness of medicinal treatment of small AAAs.

Results

Statins, beta blockers and angiotensin-converting enzyme (ACE) inhibitors reduce cardiovascular mortality in patients with AAAs and statins also reduce the growth rate of AAAs.

Conclusion

Screening programs must implement strategies to improve total cardiovascular prognosis of patients with small AAAs.     

Abdominal aortic aneurysm repair in octogenarians: myth or reality?

AIM: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair. METHODS: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate. RESULTS: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01). CONCLUSION: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.     

Aneurysmen der Bauchaorta und der Beckenarterien

Background

Therapy of abdominal aortic aneurysms (AAA) is currently based on a high level of evidence. This is not true in the same manner for iliac artery aneurysms (IAA) which are frequently associated with AAAs and occur only rarely as isolated lesions. The therapeutic principles apply in the same way to both aneurysm locations.

Objectives

New findings, improved perioperative care and the rapid development of minimally invasive techniques require a constant update which is the aim of this article concerning the therapy of AAAs and IAAs.

Material and methods

A systematic literature review was performed in PubMed and Medline and priority was given to recent publications with a high level of evidence.

Results

Endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) result in a similar long-term survival. The perioperative survival advantage with EVAR persists only during medium-term postoperative courses. The reintervention rate after EVAR is substantially higher compared to OAR. For older patients and those who are considered unfit for OAR the expected benefits from EVAR has not been proven to date. Aneurysmal ruptures after EVAR demonstrate that a life-long surveillance of these patients is necessary.

Conclusion

Therapy of AAAs and IAAs is increasingly being performed by EVAR. Even the majority of complex aneurysms are amenable to minimally invasive treatment. Nevertheless, indications for OAR continue to exist. Screening for AAAs results in a decrease of aneurysmal ruptures for which EVAR is also gaining importance.     

Assessment of pre-operative delays in the management of elective abdominal aortic aneurysms

INTRODUCTION

Successful endovascular aneurysm repair (EVAR) requires detailed pre-operative imaging to allow device planning. This process may delay surgery and some aneurysms may rupture prior to intervention. The aim of this study was to quantify these delays.

PATIENTS AND METHODS

Data were collected prospectively on all patients presenting with non-ruptured abdominal aortic aneurysms (AAAs) between January 2003 and October 2005. The delay between referral, the first out-patient visit, CT-scan, follow-up appointment and surgery were quantified in all patients and compared between two groups undergoing open repair and EVAR.

RESULTS

A total of 146 patients underwent AAA repair during the study (48 EVAR versus 98 open repair). There was no significant differences in the wait for CT scans between the groups (median 42 days for EVAR versus 47 days for open repairs [P = 0.48]) or the median interval between decision to operate and surgery (56 days versus 42 days [P = 0.075]). However, the median delay between referral and surgery was significantly longer in those patients undergoing EVAR at 129 days versus 77 days for open repair (P = 0.02).

CONCLUSIONS

Patients presenting electively with AAAs experienced significant delay from referral to surgery. This delay was significantly greater in those patients undergoing endovascular repair. Inevitably, some patients will rupture whilst waiting and strategies aimed at reducing delay should be pursued.     

Late rupture of abdominal aortic aneurysm after endovascular repair

Objective

The purpose of this study was to compare findings at presentation and surgical outcomes in patients in whom abdominal aortic aneurysms (AAAs) ruptured after endovascular repair and in patients in whom AAAs ruptured before any treatment during a defined period at a single center.

Chimney-Graft bei komplexen Aortenaneurysmen

Purpose

The aim of this article is to review the literature reporting the use of the chimney graft (CG) technique for the treatment of complex abdominal aortic aneurysms (AAA).

Methods

Studies were included in the present review if revascularization of visceral branches during endovascular treatment of complex AAAs was accomplished with the CG technique. Case reports and non-consecutive series with less than ten patients were excluded.

Results

A total of 5 publications with a total number of 94 patients fulfilled the inclusion criteria. The CG procedure was applied for the treatment of primary pararenal or juxtarenal AAAs in 78.7?% and for the repair of para-anastomotic pseudoaneurysms or endoleaks after prior open or endovascular repair in 19.2%. Of the patients 2 (2.1?%) were operated on for atheromatous aortic occlusive disease and 16 (17%) in an urgent setting. A total of 148 (average 1.57 per patient) visceral vessels were treated with CGs: 124 (83.8?%) renal arteries, 21 (14.2?%) superior mesenteric arteries (AMS) and 3 (2?%) celiac arteries (CT). Primary technical success was 96.8?% with an early type I endoleak rate of 11?%. The 30-day in-hospital mortality was 5.3?% (5.1?% and 6.3?% for elective and urgent cases, respectively) and CG patency during follow-up (mean 9.9 months) was 97.3?%. Postoperative renal function impairment occurred in 16?%, cardiac complications in 7.4?% and ischemic stroke in 3.2?% of patients.

Conclusions

Early results of the CG method demonstrate feasibility but due to the lack of long-term outcome data this technique should be currently limited to bail-out procedures or acute situations. For elective cases, fenestrated stent grafting or open repair remain the treatments of choice.     

A population-based analysis of the morbidity and mortality of gallbladder surgery in the elderly

Background

Historically, emergency gallbladder surgery in elderly patients has been associated with high rates of morbidity and mortality. Recent studies have described much lower complication rates that may still overestimate morbidity. The purpose of this study was to determine the true population morbidity and mortality rates after gallbladder surgery in the elderly.

Methods

All elderly patients (defined as age 65 years or older) admitted to the hospital with a principle diagnosis related to benign gallbladder disease in the Province of Manitoba from January 1, 1995 to December 31, 2008 were identified by using administrative claims data. Outcomes after emergency gallbladder surgery, including complication rates and their predictors, were compared with outcomes after elective surgery and after nonoperative treatment for gallbladder-related hospital admissions.

Results

A total of 9,936 patients were included: 2,355 had emergency or urgent surgery and 4,901 had elective procedures, whereas 2,680 patients were treated without surgery. Emergency gallbladder surgery was associated with a mortality rate of 0.7 %, compared with 1.6 % for elective cases and 5.6 % for patients treated nonoperatively. Complication rates were 16.2, 17.7, and 25 % respectively. Independent predictors of 30-day mortality were age, male gender, increasing comorbidity, surgeon experience, and surgical treatment.

Conclusions

Emergency gallbladder surgery in the elderly was not associated with higher mortality or complication rate compared with the elective setting. Elderly patients with gallbladder-related emergencies should be offered urgent surgery when feasible.     

Long-Term Survival and Quality of Life After Open Abdominal Aortic Aneurysm Repair

Background

Open repair of abdominal aortic aneurysm (AAA) generally involves postsurgery admission to the intensive care unit (ICU). Few studies have evaluated the impact of surgery for either ruptured or nonruptured AAA (with postoperative ICU treatment) on long-term survival and quality of life. The primary aim of this study was to quantify long-term survival and health-related quality of life (HrQpL) of a cohort of patients undergoing open AAA repair after hospital discharge.

Methods

Consecutive patients undergoing open elective or acute AAA reconstruction with postoperative admission to the ICU and discharged alive from the hospital during 2009 were identified. Primary outcome measures were 1-year and long-term mortality. The secondary outcome was the HrQoL using the EuroQol-6D (EQ-6D) questionnaire at the end of the follow-up period.

Results

A total of 263 patients were treated and postoperatively discharged alive: 56 had a ruptured AAA (rAAA), 35 a symptomatic AAA, and 172 an asymptomatic AAA. The 1-year mortality after open AAA repair was 8 %. Overall, 39 % of patients died within 10 postoperative years (mean 6.0 ± 2.8 years). Long-term survival of patients with a ruptured or symptomatic aneurysm was similar to that of patients undergoing elective aneurysm repair. Long-term HrQoL of the total study population was worse than that of an age-matched general Dutch population on the EQ-us (range 0–1, difference 0.12). This decrease in HrQoL was mainly seen in mobility, self-care, usual activities, and cognition.

Conclusions

Ten years after open AAA repair, the overall survival rate was 59 %. Long-term survival and HrQoL were similar for patients with a repaired ruptured or symptomatic aneurysm and those who underwent elective aneurysm repair. There were also no differences in patients with infrarenal versus juxtarenal/suprarenal aneurysms. Surviving patients had a lower HrQoL than the age-matched general Dutch population, especially regarding mobility, self-care, usual activities, and cognition.     

A registry-based rationale for discrete intervention thresholds for open and endovascular elective abdominal aortic aneurysm repair in female patients

Objective

An evidence-based consensus for a female-specific intervention threshold for abdominal aortic aneurysms (AAAs) is missing. This study aims to analyze sex-related differences in the epidemiology of ruptured AAA to establish an intervention threshold for women.

Abdominal aortic aneurysm screening program in Poland

Background

Screening for abdominal aortic aneurysms (AAA) is currently recommended by several vascular societies. In countries where it has been introduced the prevalence of AAAs differed greatly and was mainly related to cigarette smoking. The screening program also had an enormous impact on the decrease of AAA ruptures and reduced mortality rate. These facts have led to the introduction of the first screening program for AAAs in Poland.

Objective

The aim of the study was to determine the prevalence of AAAs among men aged 60 years and older undergoing ultrasound examination of the abdominal aorta.

Material and methods

A single ultrasonography of the abdomen was performed to assess the aorta from the renal arteries to the bifurcation and the diameter of the aorta was measured at its widest point. The cut-off value for determining an aortic aneurysm was set at a diameter of ≥?30 mm. All ultrasonography measurements were performed by physicians in outpatient departments throughout the Kuyavian-Pomeranian Province. Additionally, each subject had to fill out a questionnaire with demographic data, smoking habits, existing comorbidities and familial occurrence of AAAs. The study was conducted from October 2009 to November 2011.

Results

The abdominal aorta ultrasound examinations were carried out in 1556 men aged 60 years and older. The prevalence of AAA in the study population was 6.0?% (94 out of 1556). The average age of the men was 69 years (SD 6 years, range 60–92 years). In the study population 55?% of the men smoked or had smoked and 3?% were aware of the presence of AAAs in family members. There were three risk factors significantly associated with the presence of AAAs: age (p?Conclusion The prevalence of AAAs among men in Poland is higher than in other European countries and the USA. The screening program for AAAs is an easy and reliable method for detecting early stages of the disease and risk factors which are the driving forces for the development of AAAs.     

Wie ist die Umsetzung eines AAA-Screening-Programms in Deutschland möglich?

Background

Screening programs are currently of upmost importance in health politics. Large international studies of abdominal aortic aneurysm (AAA) screening programs showed a significant decrease in aneurysm-dependent mortality. In view of these findings, AAA screening programs have been implemented in various countries with variable healthcare infrastructures.

Aim

In Germany a screening program also urgently needs to be introduced but realization depends on a variety of factors. This article presents the health service system in Germany and compares it with countries that have already established AAA screening programs. A comparative analysis of factors influencing possible conditions for introducing an AAA screening program in Germany was carried out.

Material and methods

A nationwide written survey of 2000 representatively chosen German family practitioners was carried out in order to evaluate their knowledge of AAAs, the availability of ultrasound devices and the motivation for performing the screening.

Results

A majority of German family practitioners possess the required knowledge of AAAs and the ultrasound skills to perform the screening. In addition, more than two thirds were in possession of an ultrasound device. Most practitioners were confident of performing a screening and would participate in a nationwide screening of AAAs.

Conclusion

The conditions for a nationwide implementation of an AAA screening program performed with the help of general practitioners are fulfilled, considering knowledge, motivation und ultrasound availability. Owing to the lower logistic and financial expenditures in comparison to foreign AAA screening programs, the implementation by general practitioners seems to be advantageous.     

Kardiovaskuläres Risiko bei EVAR und offener Operation des nicht rupturierten abdominalen Aortenaneurysmas

Background

Cardiovascular complications have a significant impact on the outcome of patients with an abdominal aortic aneurysm (AAA) treated by open repair (OR) or by endovascular aneurysm repair (EVAR). EVAR might be associated with fewer cardiovascular complications. This review was undertaken to analyze whether the selection of EVAR and OR has an effect on cardiovascular complications within randomized trials with intact AAA patients.

Methods

Analysis of cardiovascular complications reported in the prospective, randomised trials (RCTs) comparing EVAR and OR in the elective treatment of intact AAAs.

Results

Four RCTs give evidence that EVAR is associated with a significantly lower perioperative mortality rate. Cardiovascular mortality and complication rates do not differ significantly between the two treatment options; this is also true for the long-term follow-up. Cardiac complications are inconsistently reported and vary widely. These results are true for patients with a low or average surgical risk and an AAA which can be treated by OR and EVAR. Large registries indicate that especially for high-risk patients and patients >?80 years the cardiovascular event rate is significantly reduced by the use of EVAR rather than OR.

Conclusion

EVAR is associated with a significantly lower perioperative mortality rate. Patients with a normal or average surgical risk have similar cardiovascular outcomes. Elderly patients and high-risk patients may benefit from EVAR.     

Intraoperative management of tracheobronchial rupture after double-lumen tube intubation

Purpose

Tracheobronchial rupture is an uncommon but potentially serious complication of endotracheal intubation. In this study, the diagnosis and treatment strategies of a specific group of ruptures caused by double-lumen tube intubation are herein presented.

Methods

The medical records of 18 patients diagnosed and treated for tracheobronchial rupture after undergoing double-lumen tube intubation between January 1999 and October 2010 are analyzed retrospectively.

Results

In all cases, the ruptures occurred in the membranous portion. The average length of laceration was 2.44 ± 1.78 cm. The most common site of rupture was in the lower third of the trachea (n = 7, 39 %) or the left mainstem bronchus (n = 7, 39 %). One patient was diagnosed before incision using fiberoptic bronchoscopy, and 17 patients were diagnosed using direct vision of the rupture intraoperatively. All patients were treated successfully with surgery. There were no morbidities or mortalities recorded in relation to tracheobronchial rupture.

Conclusions

Thoracic surgeons must be alerted to the possibility for tracheobronchial rupture in patients intubated with double-lumen tubes, a procedure commonly used in thoracic surgery. Immediate repair must be performed for any laceration diagnosed intraoperatively.     

The cost-effectiveness of early surgery versus watchful waiting in the management of small abdominal aortic aneurysms

Purpose: The purpose of this study was to compare the relative cost-effectiveness of two clinical strategies for managing 4 to 5 cm diameter abdominal aortic aneurysms (AAAs): early surgery (repair 4 cm AAA when diagnosed) versus watchful waiting (monitor AAA with ultrasound size measurements every 6 months and repair if the diameter reaches 5 cm).Methods: We used a Markov decision tree to compute the expected survival in quality-adjusted life years (QALYs) for each strategy, based on literature-derived estimates for the probabilities of different outcomes in this model. We determined hospital costs for patients undergoing elective and emergency AAA repair at our center. With standard methods of cost accounting, we then calculated the additional cost per year of life saved by early surgery compared with watchful waiting (cost-effectiveness ratio, dollars/QALY).Results: Mean hospital costs for elective and emergency AAA repair were $24,020 and $43,208, respectively (1992 dollars). For our base-case analysis (60-year-old men with 4 cm diameter AAAs, with 5% elective operative mortality rate and 3.3% annual rupture rate), early surgery improved survival by 0.34 QALYs compared with watchful waiting, at an incremental cost of $17,404/QALY. Increased elective surgical mortality rate, decreased AAA rupture risk, and increased patient age all reduced the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery.Conclusions: The cost effectiveness of early surgery for 4 cm diameter AAAs in carefully selected patients compares favorably with that of other commonly accepted preventive interventions such as hypertension screening and treatment. With an upper limit of $40,000/QALY as an "acceptable" cost-effectiveness ratio, early surgery appears to be justified for patients 70 years old or younger, if the AAA rupture risk is 3%/year or more and the elective operative mortality rate is 5% or less. Although not a substitute for clinical judgment, this cost-effectiveness analysis delineates the essential tradeoffs and uncertainties in treating patients with small AAAs. (J VASC SURG 1994;19:980–91.)     

Limited Potential for Prevention of Emergency Surgery for Femoral Hernia

Background

Femoral hernias are frequently operated on as an emergency. Emergency procedures for femoral hernia are associated with an almost tenfold increase in postoperative mortality, while no increase is seen for elective procedures, compared with a background population.

Objective

The aim of this study was to compare whether symptoms from femoral hernias and healthcare contacts prior to surgery differ between patients who have elective and patients who have emergency surgery.

Methods

A total of 1,967 individuals operated on for a femoral hernia over 1997–2006 were sent a questionnaire on symptoms experienced and contact with the healthcare system prior to surgery for their hernia. Answers were matched with data from the Swedish Hernia Register.

Results

A total of 1,441 (73.3 %) patients responded. Awareness of their hernia prior to surgery was denied by 53.3 % (231/433) of those who underwent an emergency procedure. Of the emergency operated patients, 31.3 % (135/432) negated symptoms in the affected groin prior to surgery and 22.2 % (96/432) had neither groin nor other symptoms. Elective patients had a considerably higher contact frequency with their general practitioner, as well as the surgical outpatient department, prior to surgery compared with patients undergoing emergency surgery (p < 0.001).

Conclusions

Patients who have elective and patients who have emergency femoral hernia surgery differ in previous symptoms and healthcare contacts. Patients who need emergency surgery are often unaware of their hernia and frequently completely asymptomatic prior to incarceration. Early diagnosis and expedient surgery is warranted, but the lack of symptoms hinders earlier detection and intervention in most cases.     

The arcuate line hernia: operative treatment and a review of the literature

Purpose

An arcuate line hernia (ALH) is a rare diagnosis with no consensus on how to deal with this condition either when symptomatic or when found accidentally. Suggestions for laparoscopic and open operative techniques are given together with a review of the literature and a presentation of three new cases.

Material

The PubMed database was searched for publications on ALH. Identified cases, including three from our department, are reported.

Results

Five males and two females, with a median age of 53 years were identified. Three patients were correctly diagnosed on a preoperative CT scan and the rest at surgery. Two patients had bilateral ALHs and four had other concomitant hernias repaired. Small bowel was present in the hernia in three cases and sigmoid colon in one. In one case, an emergency operation was performed due to bowel incarceration. Five patients had laparoscopic repairs, three with mesh and two without. Two patients, one converted from laparoscopic to open operation, had open mesh repairs. The postoperative course was uneventful in all cases, and no recurrences have been reported at a median follow-up of 6 months.

Conclusions

A laparoscopic approach is recommended for diagnostic purposes, for pre-peritoneal mesh placement and for repair of concomitant hernias in both elective and emergency settings. Highlighting its existence might help general surgeons in interpreting an unusual finding on a CT scan or at operation.