Robotic Intracorporeal Rectus Aponeuroplasty: Early Experience of a New Surgical Technique for Ventral Hernia Repair.

Introduction: The laparoscopic intracorporeal rectus aponeuroplasty (LIRA) was developed as an alternative for minimally invasive ventral hernia repair. This technique allows the closure of the defect and restoration of the midline without tension by plication of both aponeurosis of the abdominal rectus muscles combined with a minimally invasive intraperitoneal underlay mesh repair. The objective of this study is to report our early experience with the Robotic-LIRA (R-LIRA) technique and its safety and short-term efficacy. Methods: We performed a retrospective analysis of patients undergoing R-LIRA repair for ventral hernias from March 2019 to April 2022. Results: Eight patients underwent R-LIRA from March 2019 to April 2022. Median age was 47 years (interquartile range [IQR] 34.5-62.8). Median body mass index was 34.2 kg/m2 (IQR 29.9-35.2). Four patients (50%) had a primary ventral hernia being one M2, two M3, and one M2/M3. There were three incisional hernias, being one recurrent, 6 patients (75%) had associated diastasis of the rectus muscle and 1 patient presented pure diastasis. The median hernia width was 4 cm (IQR 2-6), and the median defect area was 16 cm2 (IQR 4-42). The median mesh area was 290 cm2 (IQR 211.2-300). In all cases, a barbed suture was also used for mesh fixation, and tackers were added in 4 cases. The median operative time was 172 minutes (IQR 139.8-293.3). The median length of stay was 0.5 days (IQR 0-1.8), and the median follow-up was 20 days (IQR 16-46). Conclusion: The R-LIRA has been shown to be safe and feasible for ventral and incisional hernia repairs with or without Diastasis of the Rectus Abdominis Muscle in the short term.

A Microcosm of Disparities in Breast Cancer: Comparison Between a Private Hospital and a Safety-Net County Hospital Within Los Angeles County.

BACKGROUND: Breast cancer survival is improving due to early detection and treatment advances. However, racial/ethnic differences in tumor biology, stage, and mortality remain. The objective of this study was to analyze presumed disparities at a local level. METHODS: Breast cancer patients at a county hospital and private hospital from 2010 to 2012 were retrospectively reviewed. Demographic, clinical, pathologic, and surgical data were collected. Comparisons were made between hospital cohorts and between racial/ethnic groups from both hospitals combined. RESULTS: 754 patients were included (322 from county hospital and 432 from private hospital). All patients were female. The median age was 54 years at county hospital and 60 years at private hospital (P < .0001). Racial/ethnic minorities comprised 85% of county hospital patients vs. 12% of private hospital patients (P < .0001). County hospital patients had a higher grade, clinical/pathologic stage, HER2-positive rate, and mastectomy rate. Compared to other racial/ethnic groups, non-Hispanic white women were more likely to have lower grade and ER-positive tumors. Hispanic/Latina women were younger and were more likely to have HER2-positive tumors. Both Hispanic/Latina and non-Hispanic black women presented at higher clinical stages and were more likely to undergo neoadjuvant chemotherapy and mastectomy. DISCUSSION: At county hospital compared to private hospital, the proportion of racial/ethnic minorities was higher, and patients presented at younger ages with more aggressive tumors and more advanced disease. The racial/ethnic disparities that were identified locally are largely consistent with those identified in national database studies. These marked differences at hospitals within a diverse city highlight the need for further research into the disparities.

Robotic Inguinal Hernia Repair After Prostatectomy: How to Navigate Safely.

INTRODUCTION: In recent decades, minimally invasive approaches have found their place in treating a specific subset of patients with inguinal hernias, predominantly those with recurrent or bilateral disease. Classically, prior history of urologic pelvic operations, such as prostatectomy, has been listed as relative contraindication for minimally invasive inguinal hernia repair. As the adoption of the robotics platform continues to grow, we aim to outline a feasible robotic-assisted inguinal hernia repair technique in patients with previous prostatectomies. We report the outcomes of 15 patients who underwent repair at 2 institutions. METHODS: This is a retrospective case series of 15 patients who underwent robotic transabdominal preperitoneal approach repair of their inguinal hernias after prostatectomy. Demographics, intraoperative variables, and outcomes of our cases are described. RESULTS: Fifteen patients were included in our cohort. All patients had a history of prostatectomy (7 open, 2 laparoscopic, and 6 robotic) due to prostate cancer. Median age was 70 years old (range: 60 to 89 y), with a median body mass index of 26.3 kg/m2 (range: 20.5 to 37.4 kg/m2). Hernia defects were bilateral in 6 patients and unilateral in the remaining 9 (right; 6, left; 3). The shortest interval between prostatectomy and subsequent hernia repair was 4 months (range: 4 to 216 mo). The median operative time was 139 min (range: 91 to 281 min). All defects were repaired using a polypropylene mesh except in 1 case, where a coated monofilament polyester mesh was used after having a large peritoneal defect to close, preventing future adhesions to the bowel. Mesh sizes used were large (16×11 cm), extra-large (17×12 cm) for anatomic mesh, and 20×15 cm for the monofilament polyester mesh. The mesh was fixed in 14 of 15 cases. Fixation was accomplished with absorbable suture (n=13), barbed suture (n=1), and fibrin sealant (n=1). Peritoneal closure was always performed using a continuous running v-loc suture. There were no documented major intraoperative complications, no 30-day readmission, or recurrences recorded within the follow-up period. Postoperatively, only 2 seromas and 1 hematoma were documented during the follow-up period. CONCLUSIONS: Robotic inguinal hernia repairs in patients with previous prostatectomy is safe and feasible in most patients. Larger patient series are needed to confirm these findings.

Synthesis, LC-MS/MS analysis, and biological evaluation of two vaccine candidates against ticks based on the antigenic P0 peptide from R. sanguineus linked to the p64K carrier protein from Neisseria meningitidis.

A peptide from the P0 acidic ribosomal protein (pP0) of ticks conjugated to keyhole limpet hemocyanin from Megathura crenulata has shown to be effective against different tick species when used in host vaccination. Turning this peptide into a commercial anti-tick vaccine will depend on finding the appropriate, technically and economically feasible way to present it to the host immune system. Two conjugates (p64K-Cys1pP0 and p64K-ßAla1pP0) were synthesized using the p64K carrier protein from Neisseria meningitidis produced in Escherichia coli, the same cross-linking reagent, and two analogues of pP0. The SDS-PAGE analysis of p64K-Cys1pP0 showed a heterogeneous conjugate compared to p64K-ßAla1pP0 that was detected as a protein band at 91kDa. The pP0/p64K ratio determined by MALDI-MS for p64K-Cys1pP0 ranged from 1 to 8, being 3-5 the predominant ratio, while in the case of p64K-ßAla1pP0 this ratio was 5-7. Cys1pP0 was partially linked to 35 out of 39 Lys residues and the N-terminal end, while ßAla1pP0 was mostly linked to the six free cysteine residues, to the N-terminal end, and, in a lesser extent, to Lys residues. The assignment of the conjugation sites and side reactions were based on the identification of type 2 peptides. Rabbit immunizations showed the best anti-pP0 titers and the highest efficacy against Rhipicephalus sanguineus ticks when the p64K-Cys1pP0 was used as vaccine antigen. The presence of high molecular mass aggregates observed in the SDS-PAGE analysis of p64K-Cys1pP0 could be responsible for a better immune response against pP0 and consequently for its better efficacy as an anti-tick vaccine. Graphical abstract.

Unusual presentation of rectal squamous cell carcinoma perforation-case report and literature review.

This is an unusual case of an obstructive rectal squamous cell carcinoma (SCC), causing perforation and a pelvic abscess, requiring source control and diverting colostomy. A 50-year-old female with chronic constipation presented with worsening right buttock pain for 1 month. On exam, the patient reported right hip tenderness. A computer tomography (CT) revealed rectal wall thickening with a presacral abscess. Due to the concern of rectal perforation with abscess she was taken to the operating room for proctoscopy with biopsy, colostomy diversion and drainage of the abscess over the right buttock. Pathology reported invasive rectal SCC. Rectal SCC presents similarly to rectal adenocarcinoma but its diagnosis must include special markers for cytokeratins. The treatment approach is controversial but adequately treated offers better survival than rectal ADC. Rectal SCC is rare and treated with chemoradiation however it must also be tailored to the variable acute presentations.

Dedifferentiated liposarcoma of the scrotum. Case report and literature review.

Malignant paratesticular and spermatic cord tumors are rare and often misdiagnosed preoperatively due to clinical presentations similar to other benign scrotal mass etiologies. Only a few cases regarding giant, paratesticular liposarcomas (>10 cm) have been reported. We report a unique case of an aggressive giant dedifferentiated liposarcoma of the scrotum with osteosarcoma features in a 70-year-old patient who initially presented with indolent scrotal swelling. A CT scan showed a large, complex, solid and cystic mass (12.0 x 15.5 x 19.0 cm) in the right scrotum. With a concern of a complex hydrocele, the patient was taken to the operating room for a scrotal approach to excise the hydrocele, but the spermatic cord was not traced to any discernible testicle as the entire mass was indurated and multilocular, and was excised. Pathology revealed a dedifferentiated liposarcoma, with MDM2 amplification. The patient's course was complicated due to metastatic disease.

Pneumoperitoneum and Pneumatosis cystoides intestinalis, a dangerous mixture. A case report.

BACKGROUND: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas infiltration into the intestine wall. When gas is seen in the intestinal wall, it is usually a sign of bowel wall infarction and a surgical emergency; therefore, an adequate differentiation of benign and urgent conditions of pneumatosis intestinalis is necessary to prevent misdiagnosis and inadequate therapies. CASE PRESENTATION: We present the case of a 79-year-old male with past medical history of Alzheimer's, cholecystectomy, and umbilical hernia. PCI was identified, and conservative therapy was started. Since the patient's pain persisted, a complication was suspected, and surgery was decided. After successful treatment, the patient completely recovered. CONCLUSION: There are many benign and life-threatening causes of pneumatosis intestinalis, the imaging appearance of both may look very similar. Therefore, clinical history, physical examination, and laboratory test results are the best indicators of whether it is due to a benign or life-threatening cause. PCI must be managed with a multidisciplinary team of clinicians, radiologists, and surgeons to achieve better results for our patients.

Splenic abscess after arterial embolization: a rare cause of acute abdomen.

Splenic abscess is a rare disease and a diagnostic challenge for the medical team. Attributable to its high mortality, prompt diagnosis and treatment are essential. A high degree of clinical awareness is required in conjunction with aggressive treatment, as misleading symptoms may delay treatment and worsen the patient's prognosis. The management of splenic abscess is based on medical therapy, antibiotics and splenectomy or percutaneous drainage. We present the case of a 58-year-old patient presented with a splenic abscess after arterial embolization. He underwent surgery and completely recovered.

Giant ovarian cystadenocarcinoma in an adult patient, a rare finding in modern times.

Ovarian cancer (OC) is one of the most commonly diagnosed cancers among women. Regretfully due to its a broad spectrum of clinical behavior and challenging diagnosis most cases are diagnosed at a late stage. On rare occasions, these tumors can grow to massive sizes if left untreated, worsening the prognosis of the patient. Thanks to the advancement of medicine and diagnostic techniques, these rare cases are less frequent. Timely detection and surgery could avoid all these potentially troublesome scenarios. We report the case of a 64-year-old female with a giant 13 kg high-grade papillary serous ovarian cystadenocarcinoma, the tumor grew during a four year period and was adequately treated with surgery and is under close follow up with the oncologist. To our knowledge, this is the first case of a giant ovarian cystadenocarcinoma ever reported in Ecuador.