Safety of laparoscopic repair of incisional hernias in liver transplant recipients.

INTRODUCTION: Incisional hernia is a common complication following liver transplantation occurring in 5%-34% of patients. Traditionally, open repair was standard due to fear of abdominal adhesions, postoperative complications and lack of experience with laparoscopic techniques. Laparoscopic incisional hernia repair (LIHR) has now become routine in non-transplant patients, with improved postoperative outcomes. In this study, we compared outcomes after laparoscopic and open incisional hernia repair after liver transplantation at a high-volume liver transplant center. METHODS: We performed a retrospective cohort study including all incisional hernia repairs performed on post-liver transplant patients at a major liver transplant center in Australia from 2010 to 2021. Donor, recipient, intraoperative and postoperative variables were collected from the electronic medical record focusing on laparoscopic and open repairs. RESULTS: Between January 2010 and March 2021, 138 patients underwent incisional hernia repair: 40 laparoscopic (29%) and 98 open (71%). No difference in wound infection (2.5% vs. 7.7%, p = .243); wound dehiscence (.00% vs. 2.3%, p = .332) or hernia recurrence (16.3% vs. 23.0%, p = .352) was seen between treatment groups. For larger incisional hernias (>5 cm) we found that a laparoscopic repair reduced length of stay compared to open-repair (3.89 vs. 4.57 days, p = .026). CONCLUSION: Laparoscopic repair of larger incisional hernias reduced postoperative length of hospital stay, whilst potential advantages may include reduced wound complications and hernia recurrence. Importantly, laparoscopic repair did not increase postoperative complication rates and represents a safe technique for repair in this demographic.

Sizing Considerations for GORE Excluder in Angulated Aortic Aneurysm Necks.

BACKGROUND: Device selection for endovascular treatment of abdominal aortic aneurysms (AAAs) with necks >60° is challenging. We sought to identify whether such anatomy necessitated graft oversizing during (endovascular aneurysm repair [EVAR]), and whether this increased the risk of type 1A endoleaks. METHODS: Prospective analysis of patients undergoing implantation of a C3 Gore Excluder, with aortic anatomy defined as outside Instructions for Use (IFU) due to proximal neck angulation >60° was performed. RESULTS: Of the 1,394 patients enrolled, 127 patients (9.2%) were included, with median follow-up of 236 days. Mean neck angle was 78.0 ± 13.2%, neck length 2.88 ± 1.31, and mean graft oversize 23.5 ± 9.6%. There were 7 type 1A endoleaks (5.5% males, 5.6% females). Neither neck length, angle, nor degree of oversizing were predictors of type IA endoleak. CONCLUSIONS: In conclusion, when selecting endografts for patients with proximal neck angulation over 60°, endovascular interventionalists are not adhering to IFU. However, this was not associated with increased risk of type 1A endoleaks.

Lump at the back of my tongue. The lingual thyroid-A case report and narrative review of literature.

Although the ectopic thyroid in adults is rarely symptomatic, biochemistry and imaging workup are essential. Treatment modality of choice is dependent on patient factors, institution factors and surgeon factors. The mainstay treatment involves hormone suppression treatment with exogenous thyroid hormone. If medical management is unsuccessful, surgical excision requires an experienced team including an anaesthetist and otolaryngologist. Anaesthetic considerations are important because intubation may be a potentially difficult procedure secondary to potential serious obstruction of the upper airway. We present a case report and narrative review of the literature regarding lingual thyroid workup and management.

Pop goes the tumour! Spontaneous haemorrhage of a hepatocellular carcinoma tumour.

An 84-year-old man presented to a rural hospital in Australia with haemodynamic instability and abdominal pain. Investigation revealed haemorrhage from a lesion in his liver-an incidental finding of a hepatocellular carcinoma. Initial resuscitation and damage control surgery was performed at the peripheral hospital prior to transfer to a tertiary centre 386 km away for the second stage of management. The second stage of management included interventional radiological embolization of the bleeding liver vessel and subsequent resection of the liver tumour. This was all undertaken with new policies in place to limit the spread of infection at the peak of the COVID-19 epidemic.

Utility of digitally supported surgical competency assessments in a work-based setting: a systematic review of the literature.

BACKGROUND: Adequate training and assessment of competency in surgical trainees are important in minimizing adverse events and achieving good patient outcomes. The purpose was to investigate the current literature on digitally supported methods of facilitating work-based competency assessment of surgical trainees. METHODS: Two concurrent literature searches were performed by two independent researchers using three databases: MEDLINE, Embase and Education Resources Information Center. Eligible studies reported on digitally supported tools for assessing surgical competency in a work-based setting for interns, residents or trainees of a post-graduate surgical programme. Studies focusing primarily on training courses, simulations or other tools for assessing surgical skills in a setting outside of work were excluded. Articles published as abstracts only, articles not published in English and review articles that did not contain original data were excluded. RESULTS: A total of 11 eligible studies were included, with six of these implementing smartphone application-based programmes, and five utilizing web-based programmes. Five studies implemented the 'System for Improving and Measuring Procedural Learning' smartphone application. Studies were based predominantly on general surgery residents, and were limited to the North American context. There was significant variability between studies regarding methodology, including the scoring system used to assess competency. CONCLUSION: This review confirms that digitally supported competency assessment of surgical trainees in a work-based setting is both feasible and effective. Digital platforms allow evaluations to be performed in a timely fashion without significant disturbance to workflow.

Renal Transplant Artery Autologous Saphenous Vein Graft Aneurysms: Late Presentation and the Need for Recall and Surveillance.

Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particularly in living donors with short donor vessels or after donor vessel injury during allograft procurement. Autologous saphenous vein graft aneurysm formation is described as a late complication following the use of this conduit in renal transplant. We report a case of a 45-year-old woman who developed an autologous saphenous vein graft aneurysm 21 years after her living donor transplant, which was successfully managed with explantation of the graft, cold perfusion ex situ, and resection of the aneurysm, which was followed by reconstruction using deceased donor iliac vessels. The graft was then successfully reimplanted. Based on this experience and after a review of the literature related to autologous saphenous vein graft aneurysms in renal transplant, we recommend that surveillance for this particular complication should be considered no later than 10 years after implant of an autologous saphenous vein graft when used as an arterial conduit.

Enterocutaneous Fistula Secondary to Stump Appendicitis.

The management of appendicitis with appendicectomy is very common in surgical practice. A recognised complication of appendicitis and appendicectomy is the formation of an enterocutaneous fistula. We present the case of a seventy-five-year-old woman who presented with an appendicocutaneous fistula on the background of an open appendicectomy performed sixty years prior to presentation.

Ethanol sclerotherapy of rectal venous abnormalities in Klippel-Trenaunay syndrome.

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder characterized by the triad of capillary malformations, atypical venous malformations and varicosities and bony and/or soft tissue hypertrophy. We present the case of an 18-year-old man with KTS affected by haematochezia secondary to rectal venous malformations that was managed with endoscopic sclerotherapy. In this case, we compared the use of ethanol to phenol as a sclerosant.