Diagnosis and treatment of a rare case of an incarcerated bilateral Spigelian hernia with the vermiform appendix and caecum.

Spigelian hernia is a rare form of abdominal wall defect. Bilateral Spigelian hernias are even less common. Surgical repair of Spigelian hernias is recommended due to their high risk of incarceration and strangulation of abdominal contents. A variety of surgical approaches to repair these hernias have been described in the literature including the traditional open approach, laparoscopic transabdominal preperitoneal approach, laparoscopic intraperitoneal repair and laparoscopic totally extraperitoneal repair. Here, we present the case of an elderly female patient with rare bilateral Spigelian hernias, the right side containing incarcerated appendix and caecal pole. The left hernia was unrecognised on preoperative CT imaging. To our knowledge, very few cases have been reported in the literature. The patient underwent bilateral laparoscopic intraperitoneal mesh repair. All technical aspects of the treatment are discussed here, in the context of the current literature, including the surgical technique and the limitations of the CT diagnosis. We aim to summarise the background of these uncommon hernias, the limitations of preoperative investigations and the differences between the available operative approaches.

Impact of anaemia in oesophago-gastric cancer patients undergoing curative treatment by means of neoadjuvant chemotherapy and surgery.

BACKGROUND: The present study investigated factors associated with pre-neoadjuvant chemotherapy (NAC), and pre-operative anaemia, and examined their impact on outcomes in patients with oesophago-gastric cancer treated with curative intent. METHODS: Patients diagnosed with oesophago-gastric cancer (January 2010 to December 2015) and treated with curative intent by NAC then surgery at a tertiary centre were included. Patients were grouped by the presence of anaemia (haemoglobin <130 mg/L in males and <120 mg/L in females) and into microcytic (MCV <80 fL), normocytic (80-100 fL) and macrocytic (>100 fL) subgroups. Categorical data were analysed by chi-squared test and overall survival by univariate and multivariate Cox regression. RESULTS: 99/295 (34%) patients who received NAC were diagnosed with pre-NAC anaemia, and 157/268 (59%) of patients who subsequently underwent surgery were diagnosed with pre-operative anaemia. Normocytic anaemia was the most common, with 76 (26%) in pre-NAC and 107 (40%) in pre-operative groups. Pre-NAC anaemia was associated with increasing clinical N stage (p = 0.022), higher modified Glasgow Prognostic Score (mGPS) (p = 0.006), and a higher rate of intra-operative transfusion (p = 0.030). Pre-operative anaemia was associated with pre-NAC anaemia (p = 0.004), increasing age (p = 0.026), higher pre-operative mGPS (p = 0.021), and a higher rate of intra-operative transfusion (p = 0.021). Anaemia before NAC and surgery was associated with poorer overall survival in patient following R0 resection, independent of stage (HR 1.26, 95% CI 1.02-1.54, p = 0.030). CONCLUSION: Anaemia was associated with poorer overall survival and greater requirement for intra-operative blood transfusion in oesophago-gastric cancer patients undergoing treatment with curative intent.

Caecal metastasis from breast cancer presenting as intestinal obstruction.

BACKGROUND: Gastrointestinal metastsasis from the breast cancer are rare. We report a patient who presented with intestinal obstruction due to solitary caecal metastasis from infiltrating ductal carcinoma of breast. We also review the available literature briefly. CASE PRESENTATION: A 72 year old lady with past history of breast cancer presented with intestinal obstruction due to a caecal mass. She underwent an emergency right hemicolectomy. The histological examination of the right hemicolectomy specimen revealed an adenocarcinoma in caecum staining positive for Cytokeratin 7 and Carcinoembryonic antigen and negative for Cytokeratin 20, CDX2 and Estrogen receptor. Eight out of 11 mesenteric nodes showed tumour deposits. A histological diagnosis of metastatic breast carcinoma was given. CONCLUSION: To the best of our knowledge, this is the first case report of solitary metastasis to caecum from infiltrating ductal carcinoma of breast. Awareness of this possibility will aid in appropriate management of such patients.

Laparoscopic T-tube placement after common bile duct exploration: a simple technique.

INTRODUCTION: Laparoscopic T-tube insertion into common bile duct (CBD) can be technically challenging. We describe a technique to facilitate CBD T-tube placement. METHOD: The T-limb was cut to appropriate size and guttered along one-third of its circumference lengthwise. One end of T-limb was secured to the long stem using a tie. The free end was introduced into the abdomen through the epigastric port. Using nontraumatic graspers, this free end was advanced into the CBD. Once the whole of T-limb was inside, the tie was cut, and the T-tube would spring into place. Choledochotomy was sutured snugly around the T-tube. The long limb was taken out through the lateral port of the abdominal wall. RESULTS: There was no dislodgment or removal difficulty in all cases. This manoeuvre required <1 minute. CONCLUSIONS: This technique allows reliable and easier T-tube placement into CBD, requiring no ancillary devices. It shortens the steep learning curve. SYNOPSIS: Laparoscopic placement of T-tube in CBD can be safely and easily manipulated in the described technique.