A case report of unexpected pathology within an incarcerated ventral hernia.

INTRODUCTION: Incidence of hernial appendicitis is 0.008%, most frequently within inguinal and femoral hernias. Up to 2.5% of appendectomy patients are found to have Crohn's disease. Elucidating the etiology of inflammation is essential for directing management. PRESENTATION OF CASE: A 51-year-old female with achondroplastic dwarfism, multiple cesarean sections, and subsequent massive incisional hernia, presented with ruptured appendicitis within her incarcerated hernia. She underwent diagnostic laparoscopy, appendectomy, intra-abdominal abscess drainage, and complete reduction of ventral hernia contents. She developed a nonhealing colocutaneous fistula, causing major disruptions to her daily life. She elected to undergo hernia repair with component separation for anticipated lack of domain secondary to her body habitus. Her operative course consisted of open abdominal exploration, adhesiolysis, colocutaneous fistula repair, ileocolic resection and anastomosis, and hernia repair with bioresorbable mesh. She tolerated the procedure well. Unexpectedly, ileocolic pathology demonstrated chronic active ileitis, diagnostic of Crohn's disease. DISCUSSION: Only two cases of hernial Crohn's appendicitis have been reported, both within Spigelian hernias. Appendiceal inflammation inside a hernia sac may be attributed to ischemia from extraluminal compression of the hernia neck. This case demonstrates a rare presentation of multiple concurrent surgical disease processes, each of which impact the patient's treatment plan. CONCLUSION: This is the first report of incisional hernia appendicitis with nonhealing colocutaneous fistulas secondary to Crohn's. It is a lesson in developing a differential diagnosis of an inflammatory process within an incarcerated hernia and management of the complications related to laparoscopic hernial appendectomy in a patient with undiagnosed Crohn's disease.

Surgeons' Experiences With Patients' Concerns Regarding Trainees.

OBJECTIVE: Little is known about surgeons' attitudes toward patients' concerns about the role of trainees in their care. The nature of the discussion between surgeons and their patients about trainees and the effect on how patients are cared for is an important part of patient-centered care. We aim to elucidate surgeons' attitude toward patients' concerns regarding trainee involvement in their care. DESIGN: An electronic, web-based 15-question survey (SurveyMonkey) was used. SETTING: Surveys were sent to 528 e-mail accounts of the members of the Massachusetts Chapter of the American College of Surgeons. Surgeon demographics, the frequency and nature of patients' concerns about trainees, and the reactions to these concerns by surgeons were explored. PARTICIPANTS: Of the 528 surgeons surveyed, 109 completed the online survey. Most specialties of surgery were represented. RESULTS: We analyzed 109 responses (21% response rate). Most surgeons from a variety of specialties were involved with teaching medical students and residents. Half the respondents trained fellows as well. Patients' concerns are raised more often in the community setting where surgeons are more likely to alter their practice. CONCLUSIONS: Although patients' concerns about trainee involvement are infrequent, they arise enough to deserve specific attention in the current patient-centric environment. Surgeons successfully negotiate to have trainee involvement in the vast majority of cases. Specific guidelines should be developed and adopted to ensure that patients consent to trainee involvement and understand the role of trainees and their supervision.

Ideal timing of surgery for acute uncomplicated appendicitis.

BACKGROUND: Early surgery for appendicitis is thought to avoid complications associated with appendiceal rupture. AIMS: This study was to evaluate the effect of timing of surgery on complications, length of stay (LOS) and cost in patients undergoing appendectomy. MATERIALS AND METHODS: Retrospective review of 396 patients with appendectomies from January 1, 2005 to December 31, 2007 was performed. Demographic data, time of presentation, physical findings, diagnostic data, operating room times, LOS, cost and complications were collected. Patients were divided into 4 groups based on time from presentation to appendectomy. RESULTS: Pathology confirmed appendicitis in 354 (89%) patients. Most patients (90%) had surgery within 18 h of presentation. Timing of surgery did not affect the incidence of purulent peritonitis (P = 0.883), abscess (P = 0.841) or perforation (P = 0.464). LOS was significantly shorter for patients with emergency department registration to operating room times less than 18 h (P < 0.0001). Costs were significantly higher for patients with times to operating room greater than 18 h (P < 0.001). CONCLUSION: Timing of surgery did not affect the incidence of complications or perforated appendicitis. However, delay in surgical consultation and surgery are associated with increased LOS and increased hospital costs. The optimal timing of appendectomy for uncomplicated acute appendicitis appears to be within 18 h of emergency department presentation.