Management of abdominal wall hernias in patients with severe obesity.

Obesity is a risk factor for abdominal wall hernia development and hernia recurrence. The management of these two pathologies is complex and often entwined. Bariatric and ventral hernia surgery require careful consideration of physiologic and technical components for optimal outcomes. In this review, a multidisciplinary group of Society of American Gastrointestinal and Endoscopic Surgeons' bariatric and hernia surgeons present the various weight loss modalities available for the pre-operative optimization of patients with severe obesity and concurrent hernias. The group also details the technical aspects of managing abdominal wall defects during weight loss procedures and suggests the optimal timing of definitive hernia repair after bariatric surgery. Since level one evidence is not available on some of the topics covered by this review, expert opinion was implemented in some instances. Additional high-quality research in this area will allow for better recommendations and therefore treatment strategies for these complex patients.

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair.

BACKGROUND: Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair. METHODS: A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention. RESULTS: Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective. CONCLUSION: Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

Ruptured Cystic Mesothelioma Diagnosed after Blunt Trauma; Case Report and Literature Review.

The majority of blunt trauma is secondary to motor vehicle crashes,especially in those wearing seatbelts or sitting in the front or passenger seat location.Hollow viscus gastrointestinal injuries occur more frequently in small bowel, followed by colorectal, duodenum, stomach and appendix. A 25-year-old male presents after being involved in a motor vehicle accident. Initialworkup was significant for moderate amount of pelvic free fluid and curvilinear,cysticlike structures in the pelvis. He subsequently developed peritonitis and underwentdiagnostic laparoscopy, which revealed multiple cystic nodules arising from theperitoneum. Pathology demonstrated benign cystic mesothelioma (BCM). BCM is a very rarecondition of mesotheliallined, variably sized, fluidfilled cysts that arises from theserous, pericardial or peritoneal lining. Due to the scarcity of cases, its management and prognosis are not fully established. This singular case highlights the necessity for a clinician to have a widedifferential forunusual causes of free pelvic fluid after blunt abdominaltrauma.