Traumatic lumbar hernia repair: experience at the Royal Brisbane and Women's Hospital.

BACKGROUND: Traumatic lumbar hernias (TLH) are a rare clinical entity with fewer than 100 cases reported in the English literature worldwide. Due to the surrounding anatomy, surgical repair is often difficult. There is currently no consensus on the timing of operative repair of TLH. The aim of this study is to present a case series on the management of TLH performed at the Royal Brisbane and Women's Hospital (RBWH) utilizing both open and laparoscopic techniques with both early and delayed repairs being undertaken. METHODS: Cases were identified retrospectively from the Trauma Database at the RBWH, a tertiary-level hospital in Brisbane, Australia. RESULTS: Four cases of TLH were identified from 2009 to 2014. The diagnosis was confirmed pre-operatively on CT imaging. Early repair was undertaken when the patient was stable from other associated injuries. Herniation was managed in three cases by open repair (2x open lumbar approaches, 1 via midline laparotomy) with sublay extraperitoneal mesh placement. The remaining case was managed by laparoscopic extra-peritoneal mesh repair. At a minimal 4 months follow-up, no evidence of recurrence or complications was detected in three cases. One patient was lost to follow-up. CONCLUSIONS: TLH are a rare clinical entity. Operative management can be achieved via open or laparoscopic techniques, with placement of mesh in the extraperitoneal plane. Both early, when the patients clinical status allows, and delayed repair appear to have good short-term results. Long-term data are not available at this stage.

Planned versus unplanned portal vein resections during pancreaticoduodenectomy for adenocarcinoma.

BACKGROUND: The management of portal vein (PV) involvement by pancreatic adenocarcinoma during pancreaticoduodenectomy (PD) is controversial. The aim of this study was to compare the outcomes of unplanned and planned PV resections as part of PD. METHODS: An analysis of PD over 11 years was performed. Patients who had undergone PV resection (PV-PD) were identified, and categorized into those who had undergone planned or unplanned resection. Postoperative and oncological outcomes were compared. RESULTS: Of 249 patients who underwent PD for pancreatic adenocarcinoma, 66 (26·5 per cent) had PV-PD, including 27 (41 per cent) planned and 39 (59 per cent) unplanned PV resections. Twenty-five of 27 planned PV resections were circumferential PV-PD, whereas 25 of 39 unplanned PV resections were partial PV-PD. Planned PV resections were performed in slightly younger patients (mean(s.d.) 60(9) versus 65(10) years; P = 0·031), and associated with longer operating times (mean(s.d.) 602(131) versus 458(83) min; P < 0·001) and more major complications (26 versus 5 per cent; P = 0·026). Planned PV resections were associated with a lower rate of positive margins (4 versus 44 per cent; P < 0·001) despite being carried out for larger tumours (mean(s.d.) 3·9(1·4) versus 2·9(1·0) cm; P = 0·002). There was no difference in survival between the two groups (P = 0·998). On multivariable analysis, margin status was a significant predictor of survival. CONCLUSION: Although planned PV resections for pancreatic adenocarcinoma were associated with higher rates of postoperative morbidity than unplanned resections, R0 resection rates were better.