Restoration of intestinal continuity following emergency sigmoid colectomy for sigmoid volvulus: An American College of Surgeons National Surgical Quality Improvement Program analysis using coarsened exact matching.

BACKGROUND: There is limited data to guide decision-making between performing a primary anastomosis and fashioning an end colostomy following emergency sigmoid colectomy for patients with sigmoid volvulus. The aim of this study was to compare the outcomes of these two approaches. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2021 was retrospectively analyzed. Missing data were multiply imputed, and coarsened exact matching was performed to generate matched cohorts. Rates of major complications and other postoperative outcomes were evaluated among patients who had a primary anastomosis as compared with matched controls who had an end colostomy following emergency sigmoid colectomy. RESULTS: Overall, 4041 patients who had a primary anastomosis and 1240 who had an end colostomy met the inclusion criteria. After multiple imputation and coarsened exact matching, 895 patients who had a primary anastomosis had a matched control. The rate of major complications was lower in patients who had an end colostomy (33.2% vs. 36.7%), but this difference was not statistically significant (OR 0.86, 95% CI 0.70-1.05). Results were similar in subgroup analyses of higher-risk patients. There were no significant differences in overall complication rate, mortality, length of hospital stay, or readmission rate. Patients with a colostomy were more likely to be discharged to a care facility (OR 1.35, 95% CI 1.09-1.67). CONCLUSION: Differences in rates of major complications and many other outcomes after primary anastomosis as compared with end colostomy were not statistically significant following emergency sigmoid colectomy for sigmoid volvulus.

Impact of obesity on patients undergoing surgery for rectal cancer in Australia and New Zealand.

PURPOSE: Patients with obesity undergoing rectal cancer surgery may have an increased risk of developing complications, though evidence is inconclusive. The aim of this study was to determine the direct impact of obesity on postoperative outcomes using data from a large clinical registry. METHOD: The Binational Colorectal Cancer Audit registry was used to identify patients who underwent rectal cancer surgery in Australia and New Zealand from 2007-2021. Primary outcomes were inpatient surgical and medical complications. Logistic regression models were developed to describe the association between body-mass index (BMI) and outcomes. RESULTS: Among 3,708 patients (median age 66 years [IQR 56.75-75], 65.0% male), 2.0% had a BMI < 18.5 kg/m2, 35.4% had a BMI of 18.5-24.9 kg/m2, 37.6% had a BMI of 25.0-29.9 kg/m2, 16.7% had a BMI of 30.0-34.9 kg/m2, and 8.2% had a BMI ≥ 35.0 kg/m2. Surgical complications occurred in 27.7% of patients with a BMI of 18.5-24.9 kg/m2, 26.6% of patients with a BMI of 25.0-29.9 kg/m2 (OR 0.91, 95% CI 0.76-1.10), 28.5% with a BMI of 30.0-34.9 kg/m2 (OR 0.96, 95% CI 0.76-1.21), and 33.2% with a BMI ≥ 35.0 kg/m2 (OR 1.27, 95% CI 0.94-1.71). Modelling BMI as a continuous variable confirmed a J-shaped relationship. The association between BMI and medical complications was more linear. CONCLUSION: Risk of postoperative complications is increased in patients with obesity undergoing rectal cancer surgery.

Necrotising Fasciitis During the COVID-19 Pandemic: An Australian Hospital Network Experience.

BACKGROUND: The clinical presentations of diseases and the provision of global healthcare services have been negatively affected by the COVID-19 pandemic. Our study aimed to determine the impact of this global pandemic on presentations of necrotising fasciitis (NF). METHODS: A retrospective study was conducted of adult patients with NF in South West Sydney Local Health District from January 2017 to October 2022. An analysis of sociodemographic and clinical outcomes was performed comparing the COVID-19 cohort (2020-2022) and the pre-COVID-19 cohort (2017-2019). RESULTS: Sixty-five patients were allocated to the COVID-19 cohort, and 81 patients were in the control cohort. The presentation to hospitals of the COVID-19 cohort was significantly delayed compared to the control cohort (6.1 vs. 3.2 days, P < 0.001). Patients of the age group of 40 years and younger experienced prolonged operative time (1.8 vs. 1.0 h, P = 0.040), higher number of operations (4.8 vs. 2.1, P = 0.008), and longer total length of stay (LoS) (31.3 vs. 10.3 days, P = 0.035) during the pandemic. The biochemical, clinical, or post-operative outcomes of two groups were not significantly different. CONCLUSION: This multi-centre study showed that the COVID-19 pandemic delayed presentations of NF but did not result in any significant overall changes in operative time, ICU admissions, LoS, and mortality rate. Patients aged less than 40 years in the COVID-19 group were likely to experience prolonged operative time, higher number of operations, and greater LoS.

Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer.

PURPOSE: The tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes. METHODS: Patients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models. RESULTS: Following PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03-1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06-2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19-2.31, p = 0.003). CONCLUSION: Smokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection.

Large hiatus hernia: time for a paradigm shift?

BACKGROUND: Laparoscopic large hiatal hernia (LHH) repair remains a challenge despite three decades of ongoing attempts at improving surgical outcome. Its rarity and complexity, coupled with suboptimal initial approach that is usually best suited for small symptomatic herniae have contributed to unacceptable higher failure rates. RESULTS: We have therefore undertaken a systematic appraisal of LHH with a view to clear out our misunderstandings of this entity and to address dogmatic practices that may have contributed to poor outcomes. CONCLUSIONS: First, we propose strict criteria to define nomenclature in LHH and discuss ways of subcategorising them. Next, we discuss preoperative workup strategies, paying particular attention to any relevant often atypical symptoms, indications for surgery, timing of surgery, role of surgery in the elderly and emphasizing the key role of a preoperative CT imaging in evaluating the mediastinum. Some key dissection methods are then discussed with respect to approach to the mediastinal sac, techniques to avoid/deal with pleural breach and rationale to avoid Collis gastroplasty. The issues pertaining to the repair phase are also discussed by evaluating the merits of the cruroplasty, fundoplication types and gastropexy. We end up debating the role of mesh reinforcement and assess the evidence with regards to recurrence, reoperation rate, complications, esophageal dilatation, delayed gastric emptying and mortality. Lastly, we propose a rationale for routine postoperative investigations.

Diagnosis and Management of Adult Omental Infarction: 10-Year Case Series.

BACKGROUND: Omental infarction is a rare cause of an acute abdomen with nonspecific signs that can be easily mistaken with other more common intra-abdominal pathologies. The increased use of radiological imaging has brought this diagnosis to attention with respect to management plan. We present the experience of an Australian hospital network with the diagnosis and management of omental infarction to raise awareness of this uncommon pathology. METHODS: A retrospective review of medical records of adult patients diagnosed with omental infarction from 2010 to 2020 was conducted across four major hospitals in South Western Sydney. Data relating to clinical presentation, investigations, management and outcomes were obtained. RESULTS: Omental infarction was diagnosed in 61 patients (mean 51.1 years, range: 19-76 years old). All patients presented with nonspecific abdominal pain with the most common sites being the right iliac fossa followed by the right upper quadrant, respectively, over an average period of 2.7 days. Computed tomography and/or diagnostic laparoscopy identified omental infarction in all cases. Forty-two patients (68.9%) had successful conservative management, six failed conservative management and 19 patients had emergency laparoscopic omentectomy. The average hospital length of stay was 3.4 days with no significant morbidity or mortality. CONCLUSION: Omental infarction generally presents with nonspecific clinical signs often masquerading as other more common abdominal diagnosis like cholecystitis or appendicitis. A trial of conservative management initially coupled with appropriate imaging should be recommended within the first 24-48 h before considering surgical treatment in refractory cases.

Long-term follow-up of endoscopic totally extraperitoneal direct inguinal hernia repair using the Endoloop technique.

INTRODUCTION: The pre-tied suture Endoloop™ technique for plication of the weakened transversalis fascia is efficient in post-operative seroma prevention, after laparoscopic/endoscopic direct inguinal hernia repair. No studies have evaluated long-term tolerability of this new technique in regards to chronic pain and hernia recurrence. METHODS: Prospective longitudinal evaluation study of consecutive patients treated with Endoloop™ for M2 or M3 direct defects, during endoscopic totally extraperitoneal approach. Meshes were secured with fibrin sealant only. All patients had a minimum 2.8 years (median 5.9 years) follow-up. First outcome was chronic groin/testicular pain; secondary outcome parameters included hernia recurrence and Quality of Life (QoL). Patients were assessed by phone interview using the validated Carolinas Comfort Scale (CCS), questioned regarding recurrence and asked to present for clinical review as needed. RESULTS: 112 patients (median age 57 years) with 141 direct hernia defects were included during the study period of 2008-2014. An Endoloop™ was used on 127 occasions-79 M2 and 48 M3 direct hernias. One patient had an early recurrence requiring an open repair and was therefore excluded. Thirty-three of the remaining one hundred and eleven patients (29.7%) were lost to long-term follow-up. According to their CCS range, 70 patients (88.6%) were very satisfied with their results, 8 (10.1%) were satisfied, and only one patient (1.3%) who reported chronic groin pain was unsatisfied. There was no reported long-term hernia recurrence. CONCLUSION: The PDS Endoloop™ technique for closure of direct inguinal hernia defects is well tolerated with low risk of hernia recurrence, chronic pain, and excellent QoL. This reliability persists to long-term follow-up.

Bilateral totally extraperitoneal (TEP) repair of the ultrasound-diagnosed asymptomatic contralateral inguinal hernia.

BACKGROUND: The aim of this series is to determine the clinical utility of routine ultrasound (US) of the contralateral, clinically normal groin when a unilateral inguinal hernia is referred for hernia repair-specifically assessing the morbidity and short-term change in quality-of-life (QoL) due to repair of this occult contralateral hernia when also repairing the symptomatic side. TEP inguinal hernia repair affords the opportunity to repair any groin hernia through the same small incisions. US detects 96.6% of groin hernias with 84.4% specificity. METHODS: 234 consecutive male patients with clinically unilateral and clinically bilateral hernia were enrolled; those with a clinically unilateral hernia were sent for groin US and if positive, a bilateral TEP groin hernia repair was performed (USBH). If negative, a unilateral TEP groin hernia repair was performed (UNIH). Carolina's comfort scales (CCS) and visual analogue scores (VAS) were recorded at 2 and 6 weeks postoperatively, while a modified CCS (MCCS) was recorded for all patients preoperatively. RESULTS: Bilateral TEP repair resulted in higher VAS scores than unilateral repair at 2 weeks but not 6 weeks. CCS were worse in the USBH group than UNIH group at 2 weeks but were similar by 6 weeks. Complications' rates were similar amongst all 3 groups. Factors contributing to worse scores were: smaller hernia, complications, worse preoperative MCCS results, recurrent hernia and bilateral rather than unilateral repair. CONCLUSION: Bilateral TEP for the clinically unilateral groin hernia with an occult contralateral groin hernia can be performed without increased morbidity, accepting a minor and very temporary impairment of QoL.

Review of 1000 fibrin glue mesh fixation during endoscopic totally extraperitoneal (TEP) inguinal hernia repair.

BACKGROUND: Chronic pain is a common complication arising after conventional open herniorrhaphy and to a lesser extent postlaparoscopic inguinal hernia repairs as groin incision is avoided. Although published studies support elimination of mesh fixation during endoscopic procedures, the vast majority of surgeons will still recommend it by fear of encountering increased recurrence rates, if omitted. Regrettably, penetrating staple or tack fixation devices are the preferred methods to secure the mesh and cannot be applied at the level of the triangles of 'doom' and 'pain' where hernia tends to reoccur the most. This ongoing prospective cohort study aimed to confirm the safety and advantages of fibrin glue, as a substitute to staple mesh fixation during totally extraperitoneal (TEP) inguinal hernia repair. METHODS: Over a 10-year period, 703 patients underwent 1000 elective TEP inguinal hernia repairs. Mesh fixation was achieved using exclusively fibrin sealant. Patients were reviewed at 2, 6 weeks and thereafter on an ad hoc basis if judged necessary until complete resolution of their symptoms. Quality of life (QoL) was assessed in a subgroup of 320 patients using the Carolina Comfort Scale (CCS). RESULTS: No conversion to open surgery was observed. There were three cases of major morbidities and no mortality. Three months after surgery, only seven patients (1 %) experienced chronic groin or testicular discomfort and none of them required prescription painkillers. When using the CCS, at 2 weeks 93.1 % of the patients were either satisfied or very satisfied with their outcome. This satisfaction index increased up to 99.2 % at 6 weeks post surgery. Finally, only eight hernia recurrences (1.1 %) were reported, of which five occurred during the first month of the study. CONCLUSION: Fibrin glue mesh fixation of inguinal hernia during TEP repair is extremely safe and reliable, with a very high satisfaction index for the patients and limited risk of developing chronic pain.

A preoperative hernia symptom score predicts inguinal hernia anatomy and outcomes after TEP repair.

BACKGROUND: The Carolinas comfort scale (CCS) is an ideal tool for assessing patients' quality-of-life post hernia repair, but its use has been barely investigated preoperatively. The aim was to quantify preoperative symptoms and assess their relevance in predicting postoperative clinical outcomes following totally extraperitoneal (TEP) inguinal hernia repair. METHODS: The CCS was modified for preoperative use (modified or MCCS) by omitting mesh sensation questioning. Data collection was prospective over a 16 months period. (M)CCS questionnaires were completed preoperatively and at 2 then 6 weeks post repair. Intraoperative findings were also recorded. One hundred and four consecutive patients consented for TEP repair were included using a fibrin glue mesh fixation technique. RESULTS: All three questionnaires were completed by 88 patients (84.6 %). Preoperative MCCS scores did not differ with age, obesity, the presence of bilateral or recurrent inguinal herniae or hernia type. Higher MCCS grouping [OR 4.3 (95 % CI 1.5­12.6)] and the presence of bilateral herniae [OR 8.5 (1.2­61.8)] were predictors of persisting discomfort at 6 weeks, with lower scores on MCCS [OR 16.4 (3.9­67.6), obesity (OR 9.9 91.6­63.2)] and recurrent hernia repair [OR 11.4 (1.4­91.0)] predicting increased discomfort at 2 weeks versus preoperatively. MCCS scores were inversely correlated with the size of a direct defect (r −0.42, p = 0.011) but did not differ with the intraoperative finding of an incidental femoral and/or obturator hernia. Female sex was strongly associated with recognition of a synchronous incidental hernia (5 vs 57 %, p = 0.001). CONCLUSIONS: Pre- and post-operative scoring of hernia specific symptoms should be considered as part of routine surgical practice, to counsel patients on their expectations of pain and discomfort post repair and to select those who might be more appropriate for a watchful waiting approach. Females with inguinal hernia warrant complete assessment of their groin hernial orifices intraoperatively due to a high rate of synchronous incidental hernia.

Correspondence: Laparoscopic repair of abdominal wall hernia--"How I do it"--synopsis of a seemingly straightforward technique.

Abdominal wall hernia repairs are commonly performed worldwide in general surgery. There is still no agreed consensus on the optimal surgical approach. Since the turn of the twenty-first century, minimally invasive techniques have gained in popularity as they combine the advantages of limited abdominal wall dissection, reduced post-operative pain and risk of complications, and shorter hospital stay. Although the added cost incurred by using sophisticated laparoscopic instruments may be quite substantial, it is precisely counterbalanced by an improved morbidity rate, faster discharge home and time to return to work. Laparoscopic abdominal wall hernia repair is often challenging, as it requires good anatomical knowledge, eye-hand coordination and diversified laparoscopic skills. The objective of this article is not to present another set of personal data and to compare it with already published results on this matter, but simply to offer comprehensive guidelines on the practical aspects of this relatively new technique. Some of these steps have already been discussed but most of the time in a scattered way in the surgical literature, while others are the fruit of a personal expertise grasped over the years.

Robotic-assisted versus laparoscopic rectal surgery in obese and morbidly obese patients: ACS-NSQIP analysis.

Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges associated with obesity. The ACS NSQIP database was used to identify obese patients who underwent elective laparoscopic or robotic-assisted rectal resection from 2015 to 2016. Obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. Morbid obesity was defined as a BMI greater than or equal to 35 kg/m2. The primary outcome was unplanned conversions to open. Other outcomes measures assessed included anastomotic leak, operative time, surgical site infections, length of hospital stay, readmissions and mortality. Statistical analyses were performed using SPSS 22.0 (IBM SPSS, USA). 1490 patients had robotic-assisted and 4967 patients had laparoscopic rectal resections between 2015 and 2016. Of those patients, 561 obese patients had robotic-assisted rectal resections and 1824 patients underwent laparoscopic rectal surgery. In the obese cohort, the rate of unplanned conversion to open in the robotic group was 14% compared to 24% in the laparoscopic group (P < 0.0001). Median operative time was significantly longer in the robotic group (248 min vs. 215 min, P < 0.0001). There was no difference in anastomotic leak or systemic sepsis between the laparoscopic and robotic rectal surgery groups. In morbidly obese patients (BMI ≥ 35 kg/m2), the rate of unplanned conversion to open in the robotic group was 19% compared to 26% in the laparoscopic group (P < 0.027). There was no difference in anastomotic leak, systemic sepsis or surgical site infection rates between robotic and laparoscopic rectal resection. Multivariate analysis showed that robotic-assisted surgery was associated with fewer unplanned conversions to open (OR 0.28, P < 0.0001). Robotic-assisted surgery is associated with a decreased risk of conversion to open in obese and morbidly obese patients when compared to conventional laparoscopic surgery. However, robotic surgery was associated with longer operative time and despite improvement in the rate of conversion to open, there was no difference in complications or length of stay. Our findings are limited by the retrospective non-randomised nature of the study, demographic differences between the two groups, and the likely difference in surgeon experience between the two groups. Large randomised controlled studies are needed to further explore the role of robotic rectal surgery in obese and morbidly obese patients.

Totally extraperitoneal repair of inguinal hernia: techniques and pitfalls of a challenging procedure.

Inguinal hernia repair is the most common procedure performed worldwide in general surgery. Since the turn of the 21st century, the minimally invasive approach and in particular totally extraperitoneal (TEP) repair has gained in popularity. The concept of the TEP approach combines the advantages of anterior tension-free mesh repair (Lichtenstein repair) and the open preperitoneal approach championed by Stoppa. TEP repair uses a prosthetic mesh significantly bigger than in open herniorrhaphy, offering a complete overlap of the myopectineal orifice. TEP repair is a challenging technique with unfamiliar anatomy, a limited operative field, and long learning curve. This article provides an experienced opinion on the practical aspects of the TEP approach. Some of these steps have already been discussed in the surgical literature, while others are the fruit of a personal expertise grasped over the years with more than 1,000 TEP repairs performed.

A diagnostic workup and laparoscopic approach for median arcuate ligament syndrome.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare disorder characterized by the compression of the coeliac trunk and plexus by fibrous arches of the median ligament. It commonly occurs in young women with postprandial epigastric pain, weight loss and nausea. We present a single surgeon experience on the diagnostic approach and management of MALS with a focus on laparoscopic surgery. METHODS: A retrospective review of adult patients diagnosed with MALS during a 10-year period (2011-2021) was conducted at Bankstown-Lidcombe hospital in New South Wales, Australia. RESULTS: MALS was diagnosed in six patients (mean 46 years, range: 27-74 years old), all confirmed on mesenteric duplex ultrasound and computed tomography angiography. The most common presentations were women with post-prandial pain, exercise induced pain and an average weight loss of 14.5 kg. The median interval from onset of symptoms to surgical referral was 10.5 months. The average BMI was 24.1 kg/m2 and most had a grade III American Society of Anaesthesiologist physical status. All patients underwent laparoscopic release of median arcuate ligament with one patient requiring endovascular stenting. The mean operative time was 119 minutes with two minor post-operative complications, but no mortalities. The median hospital length of stay was 3.5 days with a median follow up of 3.5 years. CONCLUSION: Laparoscopic median arcuate ligament release with endovascular support for selected cases provides sound clinical resolution of symptoms and long-term results.

The impact of COVID-19 on delayed presentations of necrotising fasciitis.

The purpose of this study was to determine the impact of coronavirus disease 2019 (COVID-19) on the delayed presentation of necrotising fasciitis (NF). A retrospective study was conducted of adult patients (≥16 years old) diagnosed with NF at a hospital from 2017 to 2020. A quantitative comparative analysis for the COVID-19 group and control group between 2017 and 2019. Structured interviews were conducted to examine the impact of COVID-19 on patients. There were 6 patients in the COVID-19 group and 10 patients in the control group. The COVID-19 group had a longer mean onset of symptoms till hospital presentation of 4.1 days and a longer mean operative time. The COVID-19 group was more likely to be admitted to intensive care unit. Three patients in the COVID-19 group did not survive compared to survival in the counterparts. Participant responses indicated the COVID-19 pandemic did not prevent them from presenting to ED.

Why Spermatic Cord Lipomas Must be Treated as "True" Inguinal Hernias.

Lipomas of the cord are common and generally associated with an indirect hernia sac, but not always, as the lipoma may be the only pathology identified during groin exploration. Missed lipoma of the spermatic cord is unfortunately not infrequent and may lead to persistence of post-operative groin pain, with confirmation of unresected cord lipoma on postoperative ultrasound, often necessitating reoperation. We present an interesting case of a 40-years-old male with symptomatic re-recurrent left inguinal hernia following previous open and subsequent endoscopic totally extraperitoneal (TEP) mesh repair. At laparoscopy, the previously inserted extraperitoneal mesh seemed well integrated with no evidence of recurrent hernia sac. Further transabdominal preperitoneal (TAPP) approach identified a moderate-size cord lipoma that had been missed twice before. His postoperative recovery was uneventful, and his previous symptoms completely subsided. This is of significant value as lipomas of the cord may sometimes represent the only source of chronic groin pain in patients with no other clinical findings. Consequently, they should be viewed and treated as "true" inguinal hernias as per the European Hernia Society (EHS). During every inguinal hernia case, the surgeon must perform rigorous exploration of the inguinal canal, looking for any herniated adipose tissue that can be easily cleared by either reduction or resection. This is further supported by both the European Association of Endoscopic Surgery (EAES) and the International Endohernia Society (IEHS) who recommend an active search for spermatic cord lipomas in all laparo-endoscopic inguinal hernia repairs.

A decade review of emergency obturator hernia repairs.

BACKGROUND: Obturator hernia is a rare pelvic hernia associated with a high morbidity and mortality. It most commonly occurs in elderly, multiparous females with symptoms and signs of small bowel obstruction. We present an Australian hospital network experience on emergency presentations of obturator hernias highlighting differences between clinical profile and surgical management. METHODS: A retrospective review of adult patients diagnosed with acute obturator hernia during a 10 year period (2010-2020) was conducted across 10 major Sydney hospitals in New South Wales, Australia. RESULTS: Obturator hernia was diagnosed in 18 patients (mean 82.7 years, range: 60-96 years old), all confirmed on pre-operative computed tomography imaging. The most common presentations were elderly women demonstrating clinical features of a small bowel obstruction. The mean onset of symptoms from home to hospital admission was 49.4 h. Non-survivors had a significantly elevated urea level (15.6 vs. 7.8 mmol/L, p = 0.036) at presentation and a longer delay from onset of presenting symptoms to diagnosis (84.0 vs. 36.2 h, p = 0.028). Eleven patients underwent urgent laparotomy and six laparoscopic repairs. The mean operative time was 101.0 min. The average hospital length of stay was 16.2 days with a mortality rate of 27.8%. CONCLUSION: Timely diagnosis and operative intervention for obturator hernia is the cornerstone of management.

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising. This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.