A comparison of robotic enhanced-view totally extraperitoneal approach versus trans-abdominal retro-muscular approach for midline ventral hernias.

BACKGROUND: The evolution of midline ventral hernia repair has progressed from the open Rives-Stoppa technique to minimally invasive robotic approaches, notably the trans-abdominal retromuscular (TARM) and enhanced-view Totally Extraperitoneal (eTEP) methods. This study compares these two robotic techniques in repairing medium-sized midline ventral hernias. METHODS: A retrospective comparative study of electronic medical records from 2015 to 2021 was conducted on patients undergoing robotic TARM or eTEP at NYU Langone Hospital-Long Island. Data on demographics, comorbid conditions, surgical history, intraoperative details, hernia characteristics, and postoperative outcomes were analyzed. RESULTS: Both eTEP and TARM groups exhibited comparable outcomes regarding operative duration, hernia defect size, and overall complications. However, notable differences were observed in patients' BMI, implanted mesh area, mesh composition, and fixation techniques across the groups. The TARM group required a longer hospital stay (median: 1 day) in contrast to the eTEP group (median: 0 days). Additionally, eTEP patients indicated reduced postoperative pain scores (median: 2) compared to TARM (median: 3), with both differences being statistically significant (p < 0.001). CONCLUSION: The robotic eTEP approach is associated with lower post-operative pain scores, decreased hospital length of stay, and larger areas of mesh implantation as compared to the TARM approach. Other variables are largely comparable between the two techniques. LEVEL OF EVIDENCE: Level III.

Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass.

BACKGROUND: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. METHODS: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. RESULTS: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS. CONCLUSION: The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

Colon and Rectal Surgery Fellowship Applicant and Matching Trends in the United States: An Analysis of National Resident Matching Program Data.

BACKGROUND: Colon and Rectal Surgery fellowships are training programs that aim to train surgeons in the management of small bowel, colon, rectal, and anal pathologies. OBJECTIVE: We investigated trends in Colon and Rectal Surgery fellowship match to help applicants anticipate future fellowship application cycles. DESIGN: This was a retrospective cohort study of applicants in the Colon and Rectal Surgery match from 2009 to 2023. Proportion of positions filled, match rates, and rank-order lists were collected. The impact of US-MD, non-US-MD, and DO status on match rate was assessed. We used the Mann Kendall trend test to obtain tau statistic and P-value for temporal trends over time, while associations between categorical variables were investigated by a chi-square test. RESULTS: Fellowship programs increased from 43 to 67, positions increased from 78 to 110, and number of applicants rose from 113 to 135. Nearly all positions were filled from 2009 to 2023 (range: 96.3%-100%). The overall match rate fluctuated between 67.3% and 80.7%. The match rate over the past 5 years was 72.0%. The match rate for US-MDs was 80.0%, while non-US-MDs had a 56.2% match rate. The percentage matching at each rank were first choice 28.0%, second choice 10.4%, third choice 6.9%, and fourth choice or lower 23.5%. CONCLUSION: Despite an increase in Colon and Rectal Surgery fellowship positions, the overall match rate has not changed significantly over the years, mainly as a result of increased applicants.

Transesophageal echocardiography-associated gastrointestinal injuries: systematic review and pooled rates of gastrointestinal injuries.

Upper gastrointestinal (GI) injuries are associated with transesophageal echocardiography (TEE) complications. We reviewed rates and various types of complications with GI injuries. A comprehensive literature search using five databases was conducted. Pooled rates were calculated for overall injuries, pooled GI complications, lacerations, and perforations with a 95% confidence interval (CI). A total of 26 studies involving 55,319 patients met inclusion criteria. The overall rate of adverse events was 0.51% (95% CI 0.3% to 0.7%). Bleeding was the most commonly reported adverse event, followed by dysphagia and lacerations. The highest rate of adverse events was observed in liver transplant patients (1.35%), followed by critically ill patients in the intensive care unit (1.1%), hospitalized patients (1.1%), patients undergoing intraoperative TEE (0.7%), and those undergoing cardiac procedures (0.67%). The pooled complication rate for bleeding was 0.17% (95% CI 0.1% to 0.3%), while odynophagia/dysphagia had a rate of 0.27% (95% CI -0.1% to 0.5%) and lacerations had a rate of 0.12% (95% CI -0.1% to 0.5%). A subgroup analysis comparing variceal and nonvariceal cohorts from three studies showed no significant difference in bleeding rates. Our study findings showed a low risk of esophageal injury in patients undergoing TEE.

Temporal trends in mortality location in patients with anal cancer in the USA: an analysis of the National Center for Health Statistics mortality data.

OBJECTIVES: Investigate trends in where patients died of anal cancer in the USA. METHODS: Retrospective cohort study using the US National Center for Health Statistics Wide-Ranging ONline Data for Epidemiologic Research platform from 2003 to 2020; all patients with death certificates listing anal cancer as the underlying cause of death in the USA. Main outcome measure of location of patient death: inpatient facility, home, hospice, nursing home/long-term care facility and other. RESULTS: There were a total of 16 296 deaths with anal cancer as the underlying diagnosis during the study period. The crude rate increased from 0.191 per 100 000 deaths in 2003 to 0.453 per 100 000 deaths in 2020. Over the study period, 22.4% of patient deaths occurred in inpatient facilities, 44.9% at home, 12.2% at hospice facilities and 13.1% at nursing homes/long-term care facilities. The percentage of deaths occurring in hospice facilities increased from 1.0% to 13.3% during the study period. Deaths at home also increased from 42.7% in 2003 to 55.8% in 2020. Meanwhile, inpatient deaths decreased from 33.5% in 2003 to 14.4% in 2020. CONCLUSIONS: There has been a significant increase in the proportion of patients with anal cancer dying at home or hospice from 2003 to 2020.

Predictors of in-hospital appendiceal perforation in patients with non- perforated acute appendicitis with appendicolithiasis at presentation.

INTRODUCTION: Appendicolithiasis is a risk factor for perforated acute appendicitis. There is limited inpatient data on predictors of progression in appendicolithiasis-associated non-perforated acute appendicitis. METHODS: We identified adults presenting with appendicolithiasis-associated non-perforated acute appendicitis (on computed tomography) who underwent appendectomy. Logistic regression was used to investigate predictors of in-hospital perforation (on histopathology). RESULTS: 296 patients with appendicolithiasis-associated non-perforated acute appendicitis were identified; 48 (16.2%) had perforation on histopathology. Mean (standard deviation [SD]) age was 39 (14.9) years. The mean (SD) length of stay (LOS) was 1.5 (1.8) days. LOS was significantly longer with perforated (mean [SD]: 3.0 [3.1] days) vs. non-perforated (mean [SD]: 1.2 [1.2] days) appendicitis (p < 0.001). On multivariate analysis, in-hospital perforation was associated with age > 65 years (OR 5.4, 95% CI: 1.4- 22.2; p = 0.015), BMI > 30 kg/m2 (OR 3.5, 95% CI: 1.3-8.9; p = 0.011), hyponatremia (OR 3.6, 95% CI: 1.3-9.8; p = 0.012). There was no significant association with age 25-65 years, gender, race, steroids, time-to- surgery, neutrophil percentage, or leukocyte count. CONCLUSION: Geriatric age, obesity, and hyponatremia are associated with progression to perforation in appendicolithiasis-associated non-perforated acute appendicitis.

Single-Incision Laparoscopic Cholecystectomy Using the Marionette Transumbilical Approach Is Safe and Efficient with Careful Patient Selection: A Comparative Analysis with Conventional Multiport Laparoscopic Cholecystectomy.

Objectives The "marionette technique" for transumbilical laparoscopic cholecystectomy (m-TLC) offers improved cosmesis and possibly shorter postoperative recovery for patient undergoing laparoscopic cholecystectomy versus the four-port conventional laparoscopic cholecystectomy (CLC). We compared the outcomes of m-TLC and CLC at a tertiary care facility in New York. Methods A retrospective chart review was conducted and data on patients who underwent m-TLC and CLC were retrieved. Hospital length of stay (LOS), operative time, and complications were compared between the two groups using linear and logistic regression, as appropriate. Results M-TLC group patients were significantly younger, predominantly females with lower body mass index. They were less likely to have previous abdominal surgery and more likely to have noninflammatory pathology ( p < 0.05 for all). Nonadjusted LOS (1 vs. 3 days, p -value < 0.0001) and operative time (50 vs. 56 minutes, p -value = 0.007) were significantly lower among patients who underwent m-TLC; however, there was no significant difference on multivariate analysis. In multivariate analysis, there was no difference in the overall complication rate (odds ratio: 1.63; 95% confidence interval 0.02-2.39). Conclusion With careful patient selection, m-TLC offers better cosmesis with comparable safety outcomes. Level of evidence Level III.

Crossing borders to change lives: Surgical mission amidst the COVID-19 pandemic.

INTRODUCTION: During the COVID pandemic, elective global surgical missions were temporarily halted for the safety of patients and travelling healthcare providers. We discuss our experience during our first surgical mission amidst the pandemic. We report a safe and successful treatment of the patients, detailing our precautionary steps and outcomes. METHODS: Retrospective manual chart review and data collection of patients' charts was conducted after IRB approval. We entail our experience and safety steps followed during screening, operating and postoperative care to minimize exposure and improve outcomes during a surgical mission in an outpatient setting during the pandemic. The surgical mission was from February 8 to February 12, 2022. RESULTS: A total of 60 patients who were screened. 33 patients underwent surgical intervention. One patient required postoperative hospitalization for a biliary duct leak. No patient or healthcare provider tested positive for COVID at the end of the mission. The average age of patients was 46.9 years. The average operative time was 116 min, and all patients had local nerve blocks. It included 45 health work providers. CONCLUSIONS: It is safe to perform outpatient international surgery during the pandemic while following pre-selected precautions.

Coronavirus Disease 2019 and the Injured Patient: A Multicenter Review.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has been shown to affect outcomes among surgical patients. We hypothesized that COVID-19 would be linked to higher mortality and longer length of stay of trauma patients regardless of the injury severity score (ISS). METHODS: We performed a retrospective analysis of trauma registries from two level 1 trauma centers (suburban and urban) from March 1, 2019, to June 30, 2019, and March 1, 2020, to June 30, 2020, comparing baseline characteristics and cumulative adverse events. Data collected included ISS, demographics, and comorbidities. The primary outcome was time from hospitalization to in-hospital death. Outcomes during the height of the first New York COVID-19 wave were also compared with the same time frame in the prior year. Kaplan-Meier method with log-rank test and Cox proportional hazard models were used to compare outcomes. RESULTS: There were 1180 trauma patients admitted during the study period from March 2020 to June 2020. Of these, 596 were never tested for COVID-19 and were excluded from the analysis. A total of 148 COVID+ patients and 436 COVID- patients composed the 2020 cohort for analysis. Compared with the 2019 cohort, the 2020 cohort was older with more associated comorbidities, more adverse events, but lower ISS. Higher rates of historical hypertension, diabetes, neurologic events, and coagulopathy were found among COVID+ patients compared with COVID- patients. D-dimer and ferritin were unreliable indicators of COVID-19 severity; however, C-reactive protein levels were higher in COVID+ relative to COVID- patients. Patients who were COVID+ had a lower median ISS compared with COVID- patients, and COVID+ patients had higher rates of mortality and longer length of stay. CONCLUSIONS: COVID+ trauma patients admitted to our two level 1 trauma centers had increased morbidity and mortality compared with admitted COVID- trauma patients despite age and lower ISS. C-reactive protein may play a role in monitoring COVID-19 activity in trauma patients. A better understanding of the physiological impact of COVID-19 on injured patients warrants further investigation.

Improved Morbidity, Mortality, and Cost with Minimally Invasive Colon Resection Compared to Open Surgery.

Background and Objectives: Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections. Methods: We analyzed outcomes between January 1, 2016 and December31, 2018 using the Vizient® clinical database. Demographics, hospital length of stay, readmissions, complications, mortality, and costs were compared between patients undergoing elective open and minimally invasive colon resections. For bivariate analysis, Wilcoxon rank-sum test was used for continuous variables and χ2 test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses. Results: A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4-13) days vs. 4 (3 - 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 - 12,649), p < 0.0001]. Multivariable models confirmed these findings. Conclusion: Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

Diagnostic accuracy of computed tomography in differentiating peritoneal tuberculosis from peritoneal carcinomatosis.

INTRODUCTION: Peritoneal tuberculosis is difficult to diagnose as it may mimic peritoneal carcinomatosis, which has similar symptomatology. We sought to determine the diagnostic accuracy of computed tomography in differentiating peritoneal tuberculosis versus peritoneal carcinomatosis. MATERIALS AND METHODS: The associations of radiological findings in 124 patients with peritoneal carcinomatosis (n = 55) or tuberculosis (n = 69) were determined using Chi-square test. Sensitivity, specificity, positive and negative predictive value, and total diagnostic accuracy of CT imaging, with histopathology as gold standard, was determined. Subgroup analyses to determine these parameters by age (>40 years and ≤40 years) and gender (male and female) were performed. RESULTS: Mean age of study population was 44.1 ± 13.2 years with 61 males (49.2%) and 63 females (50.8%). The most common radiological abnormality in both peritoneal carcinomatosis (90.9%) and peritoneal tuberculosis (89.9%) was omental smudging, followed by presence of extraperitoneal mass (81.8%) in carcinomatosis and presence of micro-nodules in tuberculosis (88.4%). The findings significantly different in both the carcinomatosis and tuberculosis groups were high-density ascites, splenic calcification, splenomegaly, lymph node calcifications, micro-nodules, and macro-nodules. The diagnostic accuracy of CT in differentiating peritoneal tuberculosis from peritoneal carcinomatosis was 83.8%; sensitivity and specificity for peritoneal tuberculosis were 88.4% and 78.2%, respectively. CONCLUSION: The diagnostic accuracy of CT in differentiating peritoneal tuberculosis from peritoneal carcinomatosis revealed an overall diagnostic accuracy of 83.8%. Subgroup analysis revealed that CT may be a more specific diagnostic tool to predict peritoneal tuberculosis in female patients and in those over 40 years old.

Herniation Through Defects in the Broad Ligament.

BACKGROUND: We sought to assess hernia characteristics and classification through comprehensive review of the literature involving broad ligament herniation. METHODS: A literature search via MEDLINE and Embase databases was conducted to identify and select broad ligament herniation studies published between January 1, 2000 and September 30, 2020. Extracted data included previous surgical history, previous obstetric history, diagnostic imaging, herniated organ, hernia classification, and repair performed. The reported data has been compared to a unique case of broad ligament herniation that presented to our institution. RESULTS: A total of 44 articles with 49 cases were identified for the study. Eighteen (36.7%) patients had a history of previous abdominal surgery while 29 (59.2%) had a history of previous childbirth. Type I (51.0%) and Type II (18.4%) defects were most commonly reported with most patients reporting only one defect (85.7%) using the Cilley classification. Twenty-nine patients underwent primary laparoscopic repair of the defect while 19 patients underwent exploratory laparotomy. CONCLUSIONS: The analysis of previously reported cases adds to the limited literature on broad ligament hernias and highlights the surgical management of this uncommon pathology. It also highlights the need for a broad differential diagnosis when female patients present with pelvic pain or symptoms of small bowel obstruction. The broad ligament should be fully inspected when mesenteric defects are suspected as multiple defects can be present as evidenced by the attached case study.

Detection of cervical spine trauma: Are 3-dimensional reconstructed images as accurate as multiplanar computer tomography?

INTRODUCTION: This study was conducted to assess the diagnostic accuracy of three-dimensional computed tomography (3D-CT) in detection of cervical spine injuries in symptomatic post-trauma patients using multiplanar computed tomography (MP-CT) as reference standard. APPROACH: This cross-sectional study was conducted at Aga Khan University from July 2016 to January 2017. Patients were included using a non-probability, consecutive sampling. MP-CT and 3D- CT images were obtained and evaluated by a senior radiologist to identify cervical spine injuries. RESULTS: 205 patients were included in the study. For fractures, 3D-CT images had sensitivity of 71%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 96.8% and diagnostic accuracy of 97%. For dislocations, 3D-CT reported sensitivity of 83.34%, specificity of 100%, positive predictive value of 100% and negative predictive value of 99.5% and diagnostic accuracy of 99.5%. CONCLUSION: 3D-CT has good diagnostic accuracy for injuries of the cervical spine but must be reviewed simultaneously with multiplanar CT images.

Morel-Lavallée Lesion in a 35-year Female.

Morel-Lavallée lesion is a post-traumatic degloving cyst, usually filled with blood, lymph or necrotic tissue, which mostly develops in the area around greater trochanter. Early diagnosis and prompt treatment is essential to prevent further complications, such as compression of surrounding structures. X-rays have limited use and magnetic resonance imaging (MRI) is the modality of choice in diagnosing the lesion. We report a case of a 35-year female presenting with left thigh pain after a fall from motorcycle almost 21/2 years ago. Ultrasound and MRI confirmed the presence of Morel-Lavallée lesion involving the left pelvis and upper thigh. Given the chronicity of lesion and extensive tissue involvement, the patient underwent surgical excision of the lesion with favourable long-term outcomes. In this case report and literature review, we discuss the pathophysiology, clinical presentation, radiological findings and management options for Morel-Lavallée lesion. Key Words: Morel-Lavallée lesion, Post-traumatic cyst, Degloving Injury, Tangential cyst.

The impact of alcohol use and withdrawal on trauma outcomes: A case control study.

INTRODUCTION: Many patients admitted to hospitals with acute trauma have positive serum blood alcohol levels. Published associations between alcohol use, injury patterns, and outcomes are inconsistent. We sought to further delineate the impact of alcohol use and alcohol withdrawal on hospital outcomes amongst acute trauma patients. METHODS: We performed a retrospective analysis of adult trauma patients hospitalized at a suburban level 1 trauma center between January 2015 and September 2019 with a blood alcohol level measurement and/or classification as alcohol withdrawal syndrome (AWS). Patients were separated into three groups: BAL ≤10 mg/dL, BAL >10 mg/dL, and alcohol withdrawal syndrome (AWS). RESULTS: Overall, 3896 patients met study criteria with 75.6% BAL ≤10, 23.2% BAL >10, and 1.2% AWS. The median age was significantly different (BAL ≤ 10: 59 years, BAL > 10: 44 years, AWS: 53.5 years). Alcohol withdrawal was experienced by patients with BAL ≤10 and BAL >10. While injury severity and mortality were similar across all 3 groups, AWS patients experienced significantly longer hospital and ICU lengths of stay, unplanned ICU admission, need for mechanical ventilation, and higher rates of complications. Patients with AWS had high rates of acute neuropsychiatric symptoms, complicating their management. CONCLUSIONS: Except for mortality, AWS patients experienced worse outcomes. The complex nature of alcohol withdrawal cases, including the possibility of developing AWS despite a negative BAL on admission, emphasizes the need for early assessment for alcohol withdrawal risk factors and input from specialists.

Isosulfan Blue and Anaphylaxis.

Background: Isosulfan blue dye, or Lymphazurin, is commonly used for sentinel lymph node biopsy during operative procedures for patients with breast cancer. Allergic reactions to Lymphazurin have been reported, ranging from mild dermatologic reactions to severe anaphylaxis. Case Series: We report 2 patients who experienced allergic reaction to Lymphazurin while admitted to our service. We also conducted a literature search for similar cases using national databases. Included studies were limited to retrospective studies, case series, or case reports. Patient characteristics, reaction observed, and hospital course were extracted. Of the patients we report, both had grade 3 anaphylactic reactions requiring vasopressors to achieve hemodynamic stability. One patient required intensive care unit monitoring for 18 hours, and the other required overnight monitoring in the postanesthesia care unit. The literature revealed 29 studies reporting 108 patients with confirmed allergic reactions to Lymphazurin. Including the 2 patients in this series (total study n=110), most reactions were grade 3 (57/110, 51.8%), followed by grade 1 (40/110, 36.4%) and grade 2 (13/110, 11.8%). Among the patients who had individual hospital course reported (n=34), 23 patients required admission to the surgical intensive care unit. Of studies that reported cancellation or progression of surgery after the reaction, the surgical procedure was canceled for 12 of 26 patients (46.1%). Conclusion: Although severe anaphylactic reactions are more commonly reported, mild reactions occur more frequently but are likely underreported. Although no fatalities were reported in the cases included in this review, anaphylactic reactions to Lymphazurin pose significant risks. Operating room personnel should be familiar with potential reactions to recognize and treat them early.

Laparoscopic repair of incarcerated transverse colon internal hernia in a patient with Crohn's disease.

Internal hernia is a rare cause of bowel obstruction in patients with no prior surgical history. Laparoscopic repair of a transverse bowel herniation through the foramen of Winslow is the rarest type of internal hernia, with only two case reports published in the literature. In a patient with a history with Crohn's disease and no prior surgical history, presenting with signs of bowel obstruction, and no inflammatory symptoms, internal hernia should be suspected as one of the causes. Minimally invasive laparoscopic repair is a feasible safe option in those patients, allowing patients to go home the next day postoperatively.

Cardiac tamponade in COVID-19 patients: Management and outcomes.

IMPORTANCE: Cardiac tamponade requiring emergent intervention is a possible complication of coronavirus disease 2019 (COVID-19) infection. Favorable clinical outcomes are possible if timely management and drainage are performed unless ventricular failure develops. OBSERVATION: Cardiac tamponade in COVID-19, based on the limited reported cases, seems to be more common among middle-aged men with observed complications in black and ethnic minorities. Prognosis is worse amongst patients with concomitant ventricular failure. DESIGN AND METHODS: This is a case series of three COVID-19 patients complicated by cardiac tamponade, requiring surgical intervention at a single institution in New York. INTERVENTION: Pericardial window, Pericardiocentesis. OUTCOME: One patient had recurrence of cardiac tamponade with hemorrhagic component but fully recovered and was discharged home. Two patients developed cardiac tamponade with concomitant biventricular failure, resulting in death. CONCLUSION AND RELEVANCE: Cardiac tamponade with possible concomitant biventricular failure can develop in COVID-19 patients; incidence seems to be highest at the point of marked inflammatory response. Concomitant ventricular failure seems to be a predictor of poor prognosis.

Bullet embolization to the heart: A rare and confounding penetrating cardiac injury case report.

Gunshot wounds to the cardiac region usually result in devastating injuries. However, if bullets embolize into the myocardium without significant damage to the organ, optimal evaluation and management remains unclear. We present the case of a hemodynamically stable gunshot wound patient who presented with a bullet to the heart. Sternotomy revealed that the bullet had embolized through the superior vena cava and embedded into the apex of the right ventricle. The patient was managed without retrieval of the bullet and continues to be well despite a retained intracardiac bullet. We discuss cases of bullet embolization to the heart and the emergence of minimally-invasive approaches for management.